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Sihem Lazreg,1 Mohamed Hosny,2 Muhammad A Ahad,3 Mazen M Sinjab,4 Riadh Messaoud,5 Shady T Awwad,6 Antoine Rousseau7 1Ophthalmology Cabinet, Blida, Algeria; 2Refractive and Cornea Service, Cairo University Hospitals, Cairo, Egypt; 3Department of Ophthalmology, Anterior Segment Division, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia; 4Dr Sulaiman Al Habib Hospital, DHCC, Dubai, United Arab Emirates; 5Department of Ophthalmology, Tahar SFAR University Hospital, Mahdia, Tunisia; 6Department of Ophthalmology, American University of Beirut - Medical Center, Beirut, Lebanon; 7Department of Ophthalmology, Bicêtre Hospital, Paris-Saclay University, Le Kremlin-Bicêtre, FranceCorrespondence: Antoine Rousseau, Pierre Testas Building, Bicêtre Hospital, 78 Rue du Général Leclerc, Le Kremlin-Bicêtre, 94270, France, Tel +33145213690, Email arousseau1010@gmail.comAbstract: In the Middle East and Northern Africa (MENA), dry eye disease (DED) is often misdiagnosed or overlooked. This review summarizes a series of conversations with ophthalmologists in the region around a variety of climatic, lifestyle, and iatrogenic factors that contribute to specific features of DED in the MENA region. These considerations are further classified by patient lifestyle and surgical choices. All statements are based on discussions and formal voting to achieve consensus over three meetings. Overall, a deeper understanding of the disease characteristics of DED specific to MENA can better guide local eyecare practitioners on appropriate management and follow-up care. Additionally, population-based studies and patient and physician education on ocular surface diseases, together with the use of culturally appropriate and language-specific questionnaires can help ease the public health burden of DED in this region.Keywords: ocular surface, regional clinical practice, epidemiology, treatment, patient outcomes

Purpose: To evaluate the outcomes of patients treated with corneal allogeneic intrastromal ring segments cut with femtosecond laser (Femto-CAIRS) without concomitant corneal crosslinking., Methods: Patients with keratoconus treated with Femto-CAIRS at the American University of Beirut Medical Center were included (May 2022-January 2023). A proprietary software program was developed on the femtosecond laser to cut allogeneic segments. Visual, refractive, tomographic, aberrometric, and epithelial data by anterior segment optical coherence tomography were measured at baseline and 1, 3, 6, and 12 months postoperatively., Results: 20 eyes of 15 patients were included and followed up for 12 months. The manifest refraction spherical equivalent and cylinder improved from -6.79 ± 4.9 diopter (D) and -4.25 ± 1.8 D to -1.88 ± 2.9 D (P < 0.001) and -2.64 ± 1.4 D (P = 0.01) 12 months postoperatively, respectively. 75% of eyes gained 3 or more corrected distance visual acuity lines, most of which (65%) gained 4 lines or more 12 months postoperatively. The maximum keratometry and vertical coma decreased by 5.2 D (P < 0.001) and 1 μm (P = 0.001), respectively, 3 months postoperatively and remained stable until 12 months. The largest anterior stromal elevation over the central 5-mm diameter decreased from 36.0 ± 18.2 μm preoperatively to 19.9 ± 9.25 μm at 1 week postoperatively (P < 0.001) and remained relatively stable. Epithelial thickness over the cone increased relative to baseline starting 1 month postoperatively and becoming stable after 6 months while the mean epithelial thickness central to the ring peaked at 1 month after which it decreased to reach a plateau at 6 months., Conclusions: The Femto-CAIRS procedure improves visual and tomographic parameters and allows repeatable and safe results with the possibility of customization for individualized management., Competing Interests: S. Jacob holds a patent for the special trephine and other devices and processes used to create corneal allogeneic intrastromal ring segments; Madhu Instruments, Ziemer Ophthalmic Systems. F. Müller is an employee of Ziemer Ophthalmic Systems AG, Port, Switzerland. S. T. Awwad is a consultant for Ziemer Ophthalmic Systems AG. The remaining authors have no funding or conflicts of interest to disclose., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: This pilot ex vivo study and first clinical experience in Italy evaluate the impact of using pre-implantation crosslinking on all-femtosecond laser-cut corneal allogenic intracorneal ring segments (AFXL CAIRSs). Methods: Six human donor eye-bank corneas were used for this preclinical ex vivo human study. Three donor (D) corneas were used for AFXL CAIRSs. First, they were prepared with an IntraLase™ femtosecond laser (Johnson & Johnson, New Brunswick, NJ, USA). The allogenic tissue rings were crosslinked before implantation with Riboflavin-UV-A accelerated crosslinking protocol (ACXL) with a 0.1% HPMC Riboflavin isotonic solution (Vibex Rapid, Glaukos-Avedro, Burlington, MA, USA) and a new KXL UV-A emitter (Glaukos-Avedro, USA). Three corneas were used as recipients (Rs) of the AFXL CAIRSs. After completing the ex vivo phase, IRB approval and signing a specific informed consent, the first two Italian patients were treated. A single ACXL CAIRS was implanted in a 51-year-old male with 53.53 D K steep, 363 μm minimum corneal thickness (MCT) and a double ACXL CAIRS was implanted in a 46-year-old male patient with 58.30 D K steep, 443 μm MCT. The longest follow-up was at three months. Results: Crosslinking of the segments enhanced tissue stiffness and grip, facilitating manipulation and CAIRS insertion into the recipient tunnels, and the yellowish color of the crosslinked segments improved visibility. The segment's thickness and volume remained unaltered during the follow-up. Both patients improved UDVA and BSCVA. K steep and High-Order Aberrations (HOAs) were reduced and MCT increased. Conclusions: Pre-implantation ACXL facilitated CAIRS insertion preserving dimensions and volume during the follow-up, rendering this important step a promising candidate in method standardization. Functional data and MCT improved significantly without adverse events.

Aims: To develop a generative adversarial network (GAN) capable of generating realistic high-resolution anterior segment optical coherence tomography (AS-OCT) images., Methods: This study included 142 628 AS-OCT B-scans from the American University of Beirut Medical Center. The Style and WAvelet based GAN architecture was trained to generate realistic AS-OCT images and was evaluated through the Fréchet Inception Distance (FID) Score and a blinded assessment by three refractive surgeons who were asked to distinguish between real and generated images. To assess the suitability of the generated images for machine learning tasks, a convolutional neural network (CNN) was trained using a dataset of real and generated images over a classification task. The generated AS-OCT images were then upsampled using an enhanced super-resolution GAN (ESRGAN) to achieve high resolution., Results: The generated images exhibited visual and quantitative similarity to real AS-OCT images. Quantitative similarity assessed using FID scored an average of 6.32. Surgeons scored 51.7% in identifying real versus generated images which was not significantly better than chance (p value >0.3). The CNN accuracy improved from 78% to 100% when synthetic images were added to the dataset. The ESRGAN upsampled images were objectively more realistic and accurate compared with traditional upsampling techniques by scoring a lower Learned Perceptual Image Patch Similarity of 0.0905 compared with 0.4244 of bicubic interpolation., Conclusions: This study successfully developed and leveraged GANs capable of generating high-definition synthetic AS-OCT images that are realistic and suitable for machine learning and image analysis tasks., Competing Interests: Competing interests: DZR is a consultant for Carl Zeiss Meditec (Carl Zeiss Meditec AG, Jena, Germany). DZR is also a consultant for CSO Italia (Florence, Italy) and has a proprietary interest in the Artemis technology (ArcScan Inc, Golden, Colorado) through patents administered by the Cornell Center for Technology Enterprise and Commercialization (CCTEC), Ithaca, New York. The remaining authors have no proprietary or financial interest in the materials presented herein., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: To compare haze and refractive outcomes in patients undergoing combined accelerated corneal cross-linking (A-CXL) and selective wavefront-guided transepithelial photorefractive keratectomy (WG-transPRK) without mitomycin C (MMC) versus those undergoing A-CXL., Methods: This prospective study analyzed 95 eyes (86 patients) with progressive keratoconus from October 2018 to October 2022. The first group underwent CXL combined with corneal or ocular WG-transPRK (CXL+PRK, n = 52), targeting higher order aberrations (HOAs). The second underwent CXL only (n = 43), both following the same accelerated CXL protocol without MMC on the SCHWIND Amaris laser platform (SCHWIND eye-tech-solutions). Baseline and postoperative evaluations (1, 3, 6, and 12 months) included uncorrected (UDVA) and corrected (CDVA) distance visual acuity, manifest refraction, tomography, corneal HOAs, and optical coherence tomography (OCT) scans. A patented machine learning algorithm objectively detected and quantified stromal haze on OCT scans in grayscale units., Results: In both groups, anterior corneal haze reflectivity and subepithelial haze peaked at 3 months postoperatively, then progressively decreased at 6 and 12 months. Haze did not differ between groups at any time point. By 12 months, CDVA increased by 2.5 lines in the CXL+PRK group ( P < .001) and by 0.7 lines in the CXL group ( P = .10), and maximum keratometry decreased from 51.70 ± 5.10 to 47.90 ± 7.90 diopters (D) (CXL+PRK group) ( P < .001) and from 51.20 ± 5.10 to 50.30 ± 4.60 D (CXL group) ( P = .004). Corneal HOAs decreased in both groups but more in the CXL+PRK group., Conclusions: Combining CXL with WG-transPRK without MMC does not result in increased haze when compared to A-CXL alone. This combined approach achieves greater improvements in visual, topographic, and aberrometric parameters. [ J Refract Surg . 2024;40(9):e583-e594.] .

Purpose: To evaluate the intrasubject repeatability of pyramidal aberrometer measurements in a sample of keratoconus and normal eyes., Setting: American University of Beirut Medical Center, Beirut, Lebanon., Design: Prospective comparative repeatability analysis., Methods: Study population: Keratoconus and normal eyes from adult patients. Observation procedures: Each eye was evaluated with 3 consecutive acquisitions using a pyramidal aberrometer. Main outcome measures: The repeatability of different ocular higher-order aberrations and lower-order aberrations (HOAs and LOAs, respectively), and Zernike coefficients down to the fifth order, was evaluated. Repeatability was assessed by within-subject SDs (Sw), repeatability limits ( r ), and intraclass correlation coefficients (ICCs), among other parameters., Results: 72 keratoconus patients (72 eyes) and 76 normal patients (76 eyes) were included. In normal and keratoconus eyes, the ICC of total LOAs and HOAs, as well as each of the Zernike coefficients, was >0.9. The Sw for keratoconus eyes with mean maximal keratometry (Kmax) <50 diopters (D) was 0.1345 for total LOAs, 0.0619 for total HOAs, 0.0292 for horizontal coma, 0.0561 for vertical coma, and 0.0221 for spherical aberration as compared with 0.2696, 0.1486, 0.0972, 0.1497, and 0.0757 for keratoconus eyes with Kmax ≥50 D. Similar trend of better repeatability for grade 1 keratoconus and HOAs <2 D as compared with grades 2 and 3 keratoconus and eyes with HOAs >2 D were also noted., Conclusions: Ocular aberrometer measurements generated by high definition pyramidal aberrometers have high repeatability in both normal and mild keratoconus eyes and moderate repeatability, yet still clinically acceptable, in advanced keratoconus. This is of particular importance in ocular wavefront-guided treatments., (Copyright © 2024 Published by Wolters Kluwer on behalf of ASCRS and ESCRS.)

Purpose: To investigate the efficacy of incorporating Generative Adversarial Network (GAN) and synthetic images in enhancing the performance of a convolutional neural network (CNN) for automated estimation of Implantable Collamer Lens (ICL) vault using anterior segment optical coherence tomography (AS-OCT)., Methods: This study was a retrospective evaluation using synthetic data and real patient images in a deep learning framework. Synthetic ICL AS-OCT scans were generated using GANs and a secondary image editing algorithm, creating approximately 100,000 synthetic images. These were used alongside real patient scans to train a CNN for estimating ICL vault distance. The model's performance was evaluated using statistical metrics such as mean absolute percentage error (MAPE), mean absolute error (MAE), root mean squared error (RMSE), and coefficient of determination ( R 2 ) for the estimation of ICL vault distance., Results: The study analyzed 4,557 AS-OCT B-scans from 138 eyes of 103 patients for training. An independent, retrospectively collected dataset of 2,454 AS-OCT images from 88 eyes of 56 patients, used prospectively for evaluation, served as the test set. When trained solely on real images, the CNN achieved a MAPE of 15.31%, MAE of 44.68 µm, and RMSE of 63.3 µm. However, with the inclusion of GAN-generated and algorithmically edited synthetic images, the performance significantly improved, achieving a MAPE of 8.09%, MAE of 24.83 µm, and RMSE of 32.26 µm. The R 2 value was +0.98, indicating a strong positive correlation between actual and predicted ICL vault distances ( P < .01). No statistically significant difference was observed between measured and predicted vault values ( P = .58)., Conclusions: The integration of GAN-generated and edited synthetic images substantially enhanced ICL vault estimation, demonstrating the efficacy of GANs and synthetic data in enhancing OCT image analysis accuracy. This model not only shows potential for assisting postoperative ICL evaluations, but also for improving OCT automation when data paucity is an issue. [ J Refract Surg . 2024;40(4):e199-e207.] .

Purpose: To evaluate and compare functional and structural outcomes of accelerated corneal crosslinking (A-CXL) using riboflavin with hydroxypropyl methyl cellulose (HPMC) vs conventional corneal crosslinking (C-CXL) using riboflavin with dextran., Setting: American University of Beirut Medical Center, Beirut, Lebanon., Design: Retrospective analysis., Methods: Retrospective analysis of 83 eyes of 73 patients with mild to moderate keratoconus. First group (n = 44 eyes) underwent C-CXL using a 30-minute riboflavin/dextran soaking between June 2014 and March 2016. Second group (n = 39 eyes) underwent A-CXL using a 20-minute riboflavin/HPMC soaking between April 2016 and December 2017. Patients were evaluated preoperatively and at 1, 3, and 12 months postoperatively. Main outcome measures were simulated keratometry (simK), maximum axial keratometry (Kmax), demarcation line depth, and haze intensity measured using optical coherence tomography-based image analysis software., Results: Demarcation line (DL) was 298.30 ± 64.60 μm and 335.61 ± 99.76 μm for C-CXL and A-CXL groups, respectively ( P = .04). Haze profile was similar for both groups. The mean simK values were reduced from 46.93 ± 3.50 and 46.44 ± 2.93 preoperatively to 46.18 ± 3.65 and 45.54 ± 2.78 at 12 months postoperatively, for C-CXL and A-CXL, respectively ( P = .003 for both groups). The mean Kmax decreased from 52.46 ± 4.82 and 51.50 ± 3.87 preoperatively to 51.30 ± 4.42 and 50.30 ± 3.52 postoperatively, for the C-CXL and A-CXL, respectively ( P < .001 for both groups). There was no difference in the simK and Kmax changes between the C-CXL and A-CXL groups ( P = .814 and P = .913), visual acuity, and refraction between the 2 groups ( P > .05)., Conclusions: A-CXL with a 20-minute riboflavin/HPMC soaking produced deeper DL and similar corneal haze, topographic, refractive, and visual results to C-CXL with a 30-minute riboflavin/dextran soaking., (Copyright © 2023 Published by Wolters Kluwer on behalf of ASCRS and ESCRS.)

Corneal allogenic intrastromal ring segments (CAIRS) refer to the intracorneal placement of fresh, unprocessed, processed, preserved, or packaged allogenic rings/segments of any type/length. We described uniform-thickness CAIRS previously. We now describe a new technique of customized CAIRS to personalize the flattening effect as per individual topography. A prospective interventional case series of patients with pericentral/ paracentral decentered cones and gradation of keratometry with one side steeper than the other was conducted. Individually customized tapered CAIRS with variable volume, arc length, taper length, and gradient of taper were implanted. In total, 32 eyes of 29 patients with at least 1-year follow-up were included. Special double-bladed trephines and a CAIRS customizer template allowed the creation of individually customized CAIRS. Mean uncorrected distance visual acuity (UDVA) and spectacle-corrected distance visual acuity improved from 0.22 to 0.47 (P = 0.000) and from 0.76 to 0.89 (P = 0.001), respectively. Significant improvement was seen in K1, K2, Km, Kmax, topographic astigmatism, Q-value, sphere, cylinder, spherical equivalent, Root Mean Square (RMS), Higher Order Aberrations (HOA), and vertical coma (P < 0.01, 0.05). There was no significant change in the width or height of CAIRS between 1 month and last visit on anterior-segment optical coherence tomography. Five eyes continued to remain at the same UDVA, 27 eyes had at least 2 lines, and 13 eyes had at least 3 or more lines improvement in UDVA. The maximum improvement in UDVA was 7 lines. A significant difference in flattening was obtained at different zones across the tapered CAIRS. Thus, differential flattening was achieved across the cone based on the customization plan. Personalized customization was possible for each cornea, unlike limited models of progressive-thickness synthetic segments. Allogenic nature, greater customizability, efficacy, and absent need for large inventories are advantages compared to synthetic segments., (Copyright © 2023 Copyright: © 2023 Indian Journal of Ophthalmology.)

Purpose: To describe a novel technique for cutting asymmetric allogenic segments using the femtosecond laser for the management of cases of keratoconus with non-coinciding astigmatism and coma axes., Methods: Four eyes of 2 patients with irregular keratoconus and asymmetric allogenic segments were included. Visual, refractive, tomographic, and aberrometric outcomes, and optical coherence tomography (OCT) sections were measured preoperatively and 6 months postoperatively. Evaluations included slit-lamp examination, manifest refraction, uncorrected (UDVA) and corrected (CDVA) distance visual acuity, and simulated and maximum anterior keratometry (Kmax) using anterior segment OCT., Results: Spherical and cylindrical refractive errors decreased from -2.38 ± 2.96 and -2.94 ± 2.16 to -1.81 ± 2.77 ( P = .04) and -1.75 ± 2.07 ( P = .01) diopters (D), respectively, 6 months postoperatively. There was an average gain of three lines of CDVA. Kmax decreased from 50.02 ± 1.99 to 47.89 ± 3.05 D (P= .03) and coma from 1.05 ± 0.21 to 0.21 ± 0.19 D ( P = .01)., Conclusions: Asymmetric femtosecond laser-cut allogenic segments allow a higher level of customization based on size, shape, and arc length, in contrast to the limited range of available synthetic asymmetrical segments. [ J Refract Surg . 2023;39(12):856-862.] .

Purpose: To evaluate the visual, refractive, and tomographic results of patients with corneal ectasia treated with corneal allogenic intrastromal ring segments (CAIRS) insertion without concomitant corneal cross-linking., Methods: Fifty-two eyes from 39 patients with stable corneal ectasia and unsatisfactory visual acuity with contact lenses were included. All patients underwent CAIRS insertion with no concomitant corneal procedure at the American University of Beirut Medical Center between September 2019 and July 2022. Visual, refractive, topographic, aberrometric, epithelial, stromal, and segment thickness data were measured relative to baseline at 1 week, 1 month, and at least 3 months postoperatively. Evaluations included slit-lamp examination, manifest refraction, uncorrected (UDVA) and corrected (CDVA) distance visual acuity, and tomography using anterior segment optical coherence tomography., Results: Mean follow-up time was 6.9 ± 5.2 months. UDVA and CDVA improved from 0.97 ± 0.47 and 0.56 ± 0.19 preoperatively to 0.52 ± 0.21 ( P < .001) and 0.23 ± 0.19 ( P < .001) 3 months postoperatively. Manifest refraction spherical equivalent and cylinder improved from -6.71 ± 6.51 and -4.02 ± 2.24 diopters (D) preoperatively to -3.78 ± 4.07 D ( P < .001) and -2.35 ± 1.98 D ( P < .001) 3 months postoperatively, respectively. Maximum anterior keratometry and vertical coma decreased from 58.09 ± 7.92 D and 1.56 ± 1.09 µm to 52.48 ± 6.69 D ( P < .001) and 0.43 ± 0.77 µm, respectively ( P < .001). Corneal epithelium thickened proximal to the allogenic segment by 7.25 µm ( P < .001), whereas stromal elevation at the cone decreased from 38.61 ± 18.5 to 23.82 ± 13.4 µm, respectively ( P < .001). No major complications were observed and only 1 eye lost one line of CDVA., Conclusions: Treatment of corneal ectasia with CAIRS improved visual, refractive, topographic, and tomographic parameters. Epithelial thickening central to CAIRS, along with anterior stromal flattening is postulated to contribute to tomographic flattening and regularization. [ J Refract Surg . 2023;39(11):767-776.] .

Purpose: The aim of this study was to describe a new technique to facilitate the insertion of corneal allogenic intrastromal ring segments., Methods: A single-segment corneal allogenic intrastromal ring segment (CAIRS) was trephined from donor corneas and allowed to markedly dehydrate for 75 minutes before the start of the procedure with a room humidity of 35% to 45%. The duration of the insertion step and the intrastromal segment size at 1 week as measured by optical coherence tomography were compared with previously performed single-segment CAIRS procedures using the conventional technique., Results: A total of 41 eyes of 36 patients underwent 1-segment CAIRS insertion of the same trephination size (750 µm). Fifteen eyes underwent the conventional insertion procedure, and 26 eyes had a dehydrated segment inserted. The time taken to insert the CAIRS analyzed by surgical video recording starting after the femtosecond tunnel creation and initiation of the insertion to the segment ironing step was 282 ± 103 and 97 ± 23 seconds for the conventional and the dehydrated segment technique, respectively ( P < 0.001). Anterior segment optical coherence tomography performed 1 week postoperatively revealed similar segment thickness and width of 471.3 ± 54.1 μm and 1285.1 ± 191.0 μm for the conventional allogenic segments and 483.4 ± 58.3 μm and 1227.2 ± 165.2 μm for the dehydrated segments ( P = 0.515 and 0.314, respectively)., Conclusions: Markedly dehydrated corneal allogenic segments are easier and faster to insert than the nondehydrated ones while maintaining similar sizes intrastromally. This dehydration technique makes the procedure similar to the one with synthetic segments and hence reduces the learning curve., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To establish a numerical spectral-domain optical coherence tomography (SD-OCT)-based keratoconus (KC) staging system and compare it with existing KC staging systems., Setting: Eye Hospital of Wenzhou Medical University, Wenzhou, China., Designs: Retrospective case-control study., Methods: Scheimpflug tomography, air-puff tonometry, and SD-OCT were performed on 236 normal and 331 KC eyes. All SD-OCT-derived parameters of the corneal epithelium and stroma were evaluated based on their receiver operating characteristic (ROC) curves, area under the curve (AUC), sensitivity, and specificity to discriminate between normal and KC eyes. The best performing parameters were subsequently used to create an OCT-based staging system, which was compared with existing tomographic and biomechanical staging systems., Results: 236 eyes from 236 normal patients and 331 eyes from 331 KC patients of different stages were included. The highest ranked AUC ROC SD-OCT parameters, derived from stroma and epithelium, were stroma overall minimum thickness (ST: AUC 0.836, sensitivity 90%, specificity 67%) and epithelium overall SD (EP: AUC 0.835, sensitivity 75%, specificity 78%). A numerical SD-OCT staging system called STEP including 2 parameters-"ST" and "EP"-with 5 stages was proposed., Conclusions: The new SD-OCT-based KC staging system is the first to take the epithelium with its sublayer stroma information into account, showing a strong agreement to the existing staging systems. This system could be incorporated into daily practice, potentially leading to an overall improvement in KC treatment and follow-up management., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of ASCRS and ESCRS.)

Purpose: To develop and validate a deep learning neural network for automated measurement of implantable collamer lens (ICL) vault using anterior segment optical coherence tomography (AS-OCT)., Design: Cross-sectional retrospective study., Methods: A total of 2647 AS-OCT scans were used from 139 eyes of 82 subjects who underwent ICL surgery in 3 different centers. Using transfer learning, a deep learning network was trained and validated for estimating the ICL vault on OCT. A trained operator separately reviewed all OCT scans and measured the central vault using a built-in caliper tool. The model was then separately tested on 191 scans. A Bland-Altman plot was constructed and the mean absolute percentage error (MAPE), mean absolute error (MAE), root mean squared error (RMSE), Pearson correlation coefficient (r), and determination coefficient (R 2 ) were calculated to evaluate the strength and validity of the model., Results: On the test set, the model achieved a MAPE of 3.42%, an MAE of 15.82 µm, a RMSE of 18.85 µm, a Pearson correlation coefficient r of +0.98 (P < .00001), and a coefficient of determination R 2 of +0.96. There was no significant difference between the vaults of the test set labeled by the technician vs those estimated by the model: 478 ± 95 µm vs 475 ± 97 µm, respectively, P = .064)., Conclusions: Using transfer learning, our deep learning neural network was able to accurately compute the ICL vault from AS-OCT scans, overcoming the limitations of an imbalanced data set and limited training data. Such an algorithm can assist the postoperative assessment in ICL surgery., (Copyright © 2023 Elsevier Inc. All rights reserved.)

The 2020 Beirut Port explosion was one of the largest non-nuclear urban explosions in history, and resulted in a plethora of oculofacial injuries. In this retrospective study, we present the two year follow up ophthalmic outcomes of the survivors of the blast. Only 16 out of 39 patients continued follow up at our center, with 13 having delayed complications and 7 requiring further surgery. The most common delayed complications related to the eyelid, lacrimal system, and orbit. Treatment of disfiguring facial and peri-ocular scarring with laser-assisted drug delivery of topical 5-fluorouracil showed great promise and significantly improved patients' functional and well as cosmetic outcomes., Competing Interests: Declaration of competing interest The authors have no conflict of interest to disclose., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Purpose: To evaluate the long-term visual and refractive outcomes of hyperopic excimer ablation using alcohol-assisted photorefractive keratectomy (PRK) and femtosecond laser-assisted laser in situ keratomileusis (FS-LASIK)., Setting: American University of Beirut Medical Center, Beirut, Lebanon., Design: Retrospective, matched comparative study., Methods: Eyes that underwent alcohol-assisted PRK were compared to matched eyes that underwent FS-LASIK. All patients were followed up for at least 3 years after surgery. The refractive and visual outcomes of each group were compared at different postoperative time points. The main outcome measures were spherical equivalent deviation from target (SEDT), manifest refraction, and visual acuity., Results: 83 eyes underwent alcohol-assisted PRK and 83 matched eyes underwent FS-LASIK. Preoperative manifest refraction spherical equivalent was 2.44 ± 1.18 diopters (D) and 2.20 ± 0.87 D ( P = .133) in the PRK and FS-LASIK groups, respectively. Preoperative manifest cylinder was -0.77 ± 0.89 D and -0.61 ± 0.59 D ( P = .175) for the PRK and LASIK groups, respectively. 3 years postoperatively, SEDT was 0.28 ± 0.66 D and 0.40 ± 0.56 D for the PRK and LASIK groups, respectively ( P = .222), whereas manifest cylinder was -0.55 ± 0.49 D and -0.30 ± 0.34 D for PRK and LASIK, respectively ( P < .001). The mean difference vector was 0.59 ± 0.46 for PRK and 0.38 ± 0.32 for LASIK ( P < .001). 13.3% of PRK eyes and 0% of LASIK eyes had >1 D of manifest cylinder ( P = .003)., Conclusions: Both alcohol-assisted PRK and FS-LASIK are safe and effective for the treatment of hyperopia. PRK induces slightly more postoperative astigmatism than LASIK. Larger optical zones and recently introduced ablation profiles that lead to a smoother ablation surface might improve the clinical results of hyperopic PRK., (Copyright © 2023 Published by Wolters Kluwer on behalf of ASCRS and ESCRS.)

A 51-year-old man was referred for refractive surgery evaluation. Spectacle dependence and poor visual quality in both eyes was his chief complaint. He cannot tolerate contact lenses. Corrected distance visual acuity (CDVA) was 20/40 in both eyes. Manifest refraction was +5.25 -2.25 @ 90 (20/40) in the right eye and +6.25 -2.25 @ 105 (20/40) in the left eye. The patient had a history of radial keratotomy (RK) almost 30 years ago in both eyes and at the slitlamp presented 8 RK incisions, proportionally spaced between one another. All incisions were closed, and there were no relevant signs of scarring. The patient denied any history of ocular trauma, systemic disease, or medications. Corneal topography with different technologies revealed an irregular pattern with marked central flattening in both eyes, with some points below 30 diopters (D) (Supplemental Figures 1 and 2, available at http://links.lww.com/JRS/A862 and http://links.lww.com/JRS/A863, respectively). There were no signs of cataract, and fundus examination was normal. Optical coherence tomography (OCT) of the right eye revealed a more homogeneous thickness pattern, little variation between the thinnest and thickest areas, and adequate transparency (Figure 1JOURNAL/jcrs/04.03/02158034-202306000-00018/figure1/v/2023-05-31T172126Z/r/image-tiff). In the left eye, there is wide variability between the thinnest and thickest stromal points, with annular thinning and central thickening (Figure 2JOURNAL/jcrs/04.03/02158034-202306000-00018/figure2/v/2023-05-31T172126Z/r/image-tiff). Both eyes show marked epithelial irregularity. Considering this patient's current ocular status, how would you reach visual rehabilitation? Because he is contact lens intolerant, would you consider surface ablation, for example, photorefractive keratectomy (PRK) with mitomycin-C (MMC)? If that were the case, would you think of an optimized or a topography-guided (TG) treatment? Would you immediately consider a corneal transplant option? Would you instead consider a more conservative approach? Which one and why?, (Copyright © 2023 Published by Wolters Kluwer on behalf of ASCRS and ESCRS.)

Purpose: The purpose of this study is to assess the effect of various fluence levels on prophylactic corneal cross-linking (CXL) combined with femtosecond laser in situ keratomileusis (FS-LASIK-Xtra) or transepithelial photorefractive keratectomy (TransPRK-Xtra) on biomechanics, demarcation line (DL), and stromal haze., Methods: Prospective analysis where two prophylactic CXL protocols (lower/higher fluence [LF/HF]: 30 mw/cm 2 , 60/80 s, 1.8/2.4 J/cm 2 ) were performed as part of either an FS-LASIK-Xtra or TransPRK-Xtra procedure. Data were collected preoperatively and at 1 week and 1, 3, and 6 months postoperatively. Main outcome measures were (1) dynamic corneal response parameters and the stress-strain index (SSI) from Corvis, (2) actual DL depth (ADL), and (3) stromal haze on OCT images analysed by a machine learning algorithm., Results: Eighty-six eyes from 86 patients underwent FS-LASIK-Xtra-HF (21 eyes), FS-LASIK-Xtra-LF (21 eyes), TransPRK-Xtra-HF (23 eyes), and TransPRK-Xtra-LF (21 eyes). SSI increased similarly by around 15% in all groups 6 months postoperatively (p = 0.155). All other corneal biomechanical parameters were statistically significant worsening postoperatively, but the change was similar in all groups. At 1 month postoperatively, there was no statistical difference in mean ADL among four groups (p = 0.613), mean stromal haze was similar between the two FS-LASIK-Xtra groups, but higher in the TransPRK-Xtra-HF group compared with the TransPRK-Xtra-LF group., Conclusions: FS-LASIK-Xtra and TransPRK-Xtra lead to a similar ADL and improve SSI equally. Lower fluence prophylactic CXL might be recommended as it achieves similar mean ADL with potentially less induced stromal haze, especially in TransPRK. The clinical relevance and applicability of such protocols remains to be assessed., (© 2022 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

We aimed to evaluate the depth of the demarcation line following accelerated epithelium-off corneal cross-linking (A-CXL) performed at the slit lamp with the patient sitting in an upright position. Twenty-three eyes from twenty patients, undergoing epi-off A-CXL (9 mW/cm 2 for 10 min) using a CXL device at the slit lamp in the upright position. Demarcation line depth was assessed at 1 month after the procedure using anterior segment optical coherence tomography (AS-OCT) and specialized software. Surgery was uneventful in all cases. The average postoperative demarcation line depth achieved was 189.4 µm (standard deviation: 58.67 µm). The demarcation line depth achieved with patients sitting upright, receiving CXL at the slit lamp, is similar to published data on CXL performed in the supine position, suggesting that demarcation line depth is not dependent on patient orientation during CXL.

Corneal epithelium removal during photorefractive keratotomy (PRK), TransPRK, or corneal cross-linking (CXL) means that patients experience pain and inflammation after the procedure, which need to be carefully managed with topical drug regimens. One highly effective class of topical analgesics is non-steroidal anti-inflammatory drugs (NSAIDs), but these must be used carefully, as their use has been associated with delayed re-epithelialization and, in rare cases, corneal melting. However, our clinical experience has been that the concomitant use of topical corticosteroids obviates this risk. Here, we present a mechanistic explanation for our observations, our TransPRK and epithelium-off CXL protocols, and the postoperative medication regimens where topical NSAIDs are used in combination with topical steroid therapy during the first two postoperative days (where pain and inflammation levels are the highest). We detail the results of a single-center retrospective case analysis that examined eyes that underwent TransPRK ( n = 301) or epithelium-off CXL ( n = 576). Topical NSAID use in the first two postoperative days to control pain and inflammation after PRK/TransPRK or epithelium-off CXL, when used in combination with topical steroid therapy, does not appear to be associated with corneal melting or delayed epithelial healing. This approach may represent an improvement over current methods of handling post-surgical pain in procedures that require corneal epithelial debridement.

Purpose: To determine the effectiveness of parameters and indices based on biomechanical measures at discriminating fellow eyes with topographically and tomographically normal corneas in patients with keratoconus from normal control corneas., Methods: The study included 47 keratoconus suspect eyes, defined as the topographically and tomographically normal fellow eyes of patients with frank keratoconus in the other eye. Eyes were imaged using the Pentacam HR and Corvis ST (both Oculus Optikgeräte GmbH). Fellow eyes were then categorized as topographically/tomographically normal fellow eyes (TNF) and topographically/tomographically borderline fellow eyes (TBF). The ability of each of the Corvis Biomechanical Index (CBI), Tomographic and Biomechanical Index (TBI), stiffness parameter at applanation 1 (SP-A1), and stress-strain index (SSI) at discriminating between normal controls and keratoconus suspects was assessed., Results: The TBI had the best discriminative ability with the greatest area under the receiver operating characteristic (AUROC) curve value of 0.946 for normal controls versus TBF eyes, and 0.824 for normal controls versus TNF eyes. Compared to the TBI AUROC curves, SP-A1 and CBI had AUROC curve values of 0.833 ( P = .09) and 0.822 ( P = .01) for normal controls versus TBF eyes, respectively, and AUROC curve values of 0.822 ( P = .96) and 0.550 ( P = .0002) for normal controls versus TNF eyes, respectively. The TBI had the best positive predictive value for TNF and TBF eyes, followed by CBI and SP-A1., Conclusions: The TBI and the purely biomechanical parameter SP-A1 were of moderate utility in distinguishing between normal and keratoconus suspect eyes. In the absence of topographic/tomographic evidence of keratectasia, an independently abnormal biomechanical parameter may suggest an increased risk of ectasia. [ J Refract Surg . 2022;38(5):318-325.] .

Purpose: To evaluate management of keratoconic eyes with anterior stromal necrosis overlying the intracorneal ring segment (ICRS), by either ICRS explantation alone or exchange with corneal allogenic intrastromal ring segments (CAIRS)., Methods: Among 643 Intacs SK (Additional Technology, Inc) inserted at one institutional center, 16 eyes (15 patients) with overlying spontaneous anterior stromal necrosis were identified. Data included size of stromal defect and refractive and topographical findings before ICRS insertion, before anterior stromal necrosis, and 6 months after intervention., Results: The 10-year incidence of anterior stromal necrosis after femtosecond laser-assisted ICRS insertion was 5.5%. Eight eyes underwent ICRS removal only and 8 eyes had ICRS exchanged with CAIRS. In the first group, CDVA worsened from 0.14 before melt to 0.28 logMAR after removal ( P = .10), simulated keratometry (SimK) and maximum axial keratometry (Kmax) increased from 44.73 to 46.34 diopters (D) ( P = .14) and from 49.23 to 52.26 D ( P = .14), respectively, and coma worsened from 0.87 to 1.52 D ( P = .02). In the CAIRS group, CDVA of 0.16 before melt improved to 0.11 logMAR postoperatively ( P > .99), and topographic indices stabilized with SimK, Kmax, and coma mildly altering from 45.31 to 45.44 D ( P > .99), from 49.25 to 49.64 D ( P > .99) and from 0.87 to 0.81 D ( P > .99), respectively. Whether the ICRS were explanted or exchanged, the visual and topographic mean values were better than those reported before ICRS implantation, whereas higher order aberrations in eyes without CAIRS regressed to levels before ICRS insertion. At the site of melt, thinnest residual stromal thickness averaged 327 µm with ICRS removal and 490 µm with CAIRS. Eyes with larger melt areas resulted in less optimal results with CAIRS implantation., Conclusions: Early experience in the management of anterior stromal necrosis by exchange of polymethylmethacrylate ICRS with CAIRS seems to avoid stromal thinning and confer better visual and topographic results, which were more pronounced with thicker segments. The benefit of CAIRS in large stromal melts needs to be investigated. [ J Refract Surg . 2022;38(4):256-263.] .

Importance: A review of the injury patterns, treatment strategies, and responding physicians' experience during the Port of Beirut blast may help guide future ophthalmic disaster response plans., Objective: To present the ophthalmic injuries and difficulties encountered as a result of the Port of Beirut blast on August 4, 2020., Design, Setting, and Participants: A retrospective medical record review of all patients who presented to the emergency department and 13 ophthalmology outpatient clinics at the American University of Beirut Medical Center for treatment of ophthalmic injuries sustained from the explosion in Port of Beirut, Beirut, Lebanon, from August 4 to the end of November 2020. Patients were identified from emergency records, outpatient records, and operative reports., Main Outcomes and Measures: Types of ocular injuries, final best-corrected visual acuity, and need for surgical intervention were evaluated. Visual acuity was measured with correction based on noncycloplegic refraction using the Snellen medical record., Exposures: Ocular or ocular adnexal injuries sustained from the Port of Beirut explosion., Results: A total of 39 blast survivors with ocular injuries were included in this study. Twenty-two patients presented with ocular injuries on the day of the blast, and 17 patients presented within the following 3 months to the ophthalmology clinics for a total of 48 eyes of 39 patients were treated secondary to the blast. Thirty-five patients (89.6%) were adults, and 24 (61.5%) were female. A total of 21 patients (53.8%) required surgical intervention, more than half of which were urgently requested on the same day of presentation (14 [35.9%]). Most eye injuries were caused by debris and shrapnel from shattered glass leading to surface injury (26 [54.2%]), eyelid lacerations (20 [41.6%]), orbital fractures (14 [29.2%]), brow lacerations (10 [20.8%]), hyphema (9 [18.8%]), open globe injuries (10 [20.8%]), and other global injuries. Only 7 injured eyes (14.5%) had a final best-corrected visual acuity of less than 20/200, including all 4 open globe injuries with primary no light perception (8.3%) requiring enucleation or evisceration., Conclusions and Relevance: In the aftermath of the Port of Beirut explosion, a review of the ophthalmic injuries showed a predominance of shrapnel-based injuries, many of which had a delayed presentation owing to the strain placed on health care services. Reverting to basic approaches was necessary in the context of a malfunctioning electronic medical record system.

Purpose: To evaluate and compare corneal haze as determined by optical coherence tomography (OCT) after corneal cross-linking (CXL) for the treatment of mild to moderate keratoconus with or without mitomycin C (MMC) application., Methods: This was a retrospective analysis of 87 eyes of 72 patients with mild to moderate keratoconus. The first group (n = 44 eyes) underwent CXL between June 2013 and January 2015 and the second group (n = 43 eyes) underwent CXL with MMC (CXL+MMC) between February and December 2015, both following the Dresden protocol. Patients were evaluated preoperatively and at 1, 3, 6, and 12 months postoperatively. Main outcome measures were corneal reflectivity and haze reflectivity measured by a specially developed OCT image analysis software., Results: Anterior corneal reflectivity at 1 month and 1 year postoperatively was 14.79 ± 4.68 and 25.97 ± 15.01 (P < .001), and 13.88 ± 4.39 and 18.41 ± 9.25 (P = .025) for the CXL and CXL+MMC groups, respectively. The reflectivity of the anterior stromal haze region at 1 month and 1 year postoperatively was 23.15 ± 5.91 and 33.14 ± 16.58 (P = .005), and 20.58 ± 7.88 and 27.14 ± 12.80 (P = .049) for both groups, respectively. The changes in simulated keratometry from preoperatively to postoperatively were similar in both groups. The CXL+MMC group showed larger maximum keratometry flattening: 53.41 ± 6.88 diopters (D) preoperatively and 49.44 ± 5.66 D 1 year postoperatively versus 52.27 ± 5.78 and 50.91 ± 4.25 D for CXL alone (P = .008)., Conclusions: MMC application following CXL significantly increases corneal haze. Similar studies need to be performed on simultaneous CXL and photorefractive keratectomy to evaluate the role of MMC in haze formation in such procedures. [J Refract Surg. 2021;37(2):83-90.]., (Copyright 2021, SLACK Incorporated.)

Purpose: To evaluate the repeatability of curvature zone averages centered on the point of maximum curvature (Kmax) compared to that of the single-point Kmax., Design: Comparative reliability analysis., Methods: Setting: American University of Beirut Medical Center, Beirut, Lebanon., Study Population: Sixty-five eyes of 65 adult keratoconus patients. Patients with other ocular disease, history of ocular surgery or trauma, and contact lens wear within 2 weeks of image acquisition were excluded., Observation Procedures: Eyes were evaluated with 3 consecutive scans using the Galilei dual Scheimpflug-Placido system., Main Outcome Measures: Repeatability of axial and instantaneous Kmax single points, and zone averages with radii of 0.1-2.0 mm, centered on them. Repeatability was assessed by within-subject standard deviations, repeatability limits (r), and intraclass correlation coefficients., Results: Axial curvature zone averaging yielded clinically acceptable repeatability only in eyes with Kmax ≤50 diopters (D), for radii of 1.5 mm and 2.0 mm (r = 0.87 D and r = 0.76, respectively, vs r = 0.91 for the single-point axial Kmax). Compared to instantaneous Kmax, clinically acceptable repeatability was achieved with instantaneous zone averages of at least 1.5 mm radius in eyes with Kmax ≤50 D (r = 0.99 D and r = 0.70 D, respectively) and 2.0 mm radius in eyes with Kmax >50 D (r = 2.28 D and r = 0.87 D, respectively). For all eyes, the repeatability limit of the location of Kmax was 0.82 mm and 0.80 mm for axial and instantaneous curvature, respectively., Conclusions: Instantaneous curvature zone averages centered on Kmax yielded a greater improvement in repeatability than axial zone averages and reached clinical adequacy with radii of at least 1.5 mm, for eyes with Kmax ≤50 D, and with a 2.0 mm radius for eyes with Kmax >50 D., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Purpose: To evaluate the efficacy of simultaneous laser in situ keratomileusis (LASIK) and small-aperture corneal inlay (KAMRA; AcuFocus, Inc) implantation in hyperopic presbyopic eyes at 5 years postoperatively., Methods: This was a retrospective single-center study of patients with hyperopia and presbyopia who underwent simultaneous LASIK and corneal inlay implantation by two experienced refractive surgeons. These patients were regularly observed for 5 years and evaluated with serial corneal tomographies and refractive assessments for uncorrected near visual acuity (UNVA), uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), distance-corrected near visual acuity (DCNVA), and manifest refraction spherical equivalent (MRSE)., Results: Twenty-four eyes of 24 patients were included. Mean age was 53.63 ± 4.11 years (range: 47 to 63 years) and mean preoperative MRSE was +1.52 ± 0.64 diopters (D) (range: +0.50 to +3.00 D). UNVA was 0.04 ± 0.06 logMAR at 1 month and 0.02 ± 0.05 logMAR (J1+ equivalent) at 5 years postoperatively. In comparison, preoperative DCNVA was 0.44 ± 0.20 (J5/J6 equivalent) (P < .001). At 5 years postoperatively, UDVA was 0.16 ± 0.18 logMAR (20/30 Snellen equivalent), and 23 of 24 eyes (95.8%) had UNVA of J3 or better. Two eyes (8.3%) lost one line of CDVA. One corneal inlay needed readjustment but none were explanted. Eight eyes (25%) developed regression in UNVA with hyperopic shift, which responded to a 3- to 4-month course of topical steroids, with 3 eyes showing patchy haze on the undersurface of the corneal inlay., Conclusions: Simultaneous LASIK and KAMRA inlay implantation, evaluated for 5 years postoperatively, shows some efficacy and predictability in improving UDVA and UNVA in hyperopic presbyopic eyes. However, late-onset regression with hyperopic shift, possible loss of CDVA, and occasional haze remain challenges. [J Refract Surg. 2020;36(8):498-505.]., (Copyright 2020, SLACK Incorporated.)

Purpose: To introduce a customized ablation area photo-therapeutic keratectomy (PTK) technique that uses a preoperatively generated laser ablation profile to accurately match and ablate the area of the pathology., Methods: A case of mid-peripheral Salzmann's nodular degeneration causing recurrent epithelial erosion is described. The white-to-white distance, on a slit-lamp image of the patient's eye, was measured by a Placido and dual-Scheimpflug analyzer and used as a scale on a Java-based image processing program to extrapolate the focal corneal pathology's vertical and horizontal dimensions on the corneal plane. The lesion's depth was measured by corneal optical coherence tomography (OCT). Customized ablation area transepithelial PTK, tailored to the exact dimensions of the pathology was then performed in one pass, regionally ablating the area of the pathology only., Results: Complete epithelial healing was observed by the next day with unaltered visual acuity of 20/20. Corneal OCT performed at 1 and 3 months postoperatively showed near-complete resolution of the lesion. The patient was followed up for a total of 6 months with no reported symptoms of corneal erosions., Conclusions: The application of a customized laser ablation area in the treatment of Salzmann's nodular degeneration and other focal stromal pathologies avoids unnecessary epithelial and stromal ablation. This contributes to faster visual recovery and less refractive impact, especially for peripheral lesions. [J Refract Surg. 2020;36(5):340-344.]., (Copyright 2020, SLACK Incorporated.)

Purpose: To compare intraoperative vs postoperative optical coherence tomography (OCT) measurements of implantable collamer lens (ICL) vaulting., Setting: American University of Beirut Medical Center, Beirut, Lebanon., Design: Prospective observational cohort study., Methods: Patients with myopia or myopic astigmatism undergoing ICL insertion in which intraoperative OCT measurements were obtained were included. Exclusion criteria included coexisting ocular problems and previous ocular surgery. The outcome measures were ICL vaulting as determined by OCT intraoperatively and postoperatively at 1 day, 1 week, 1 month, and 3 months., Results: Forty-five eyes of 26 patients were included. Mean age was 27.23 ± 6.47 years (range 17 to 48 years), and mean manifest refraction spherical equivalent was -10.20 ± 3.92 diopters (D) (range -20.50 to -4.50 D). Mean ICL vaulting measured 731 ± 215 μm intraoperatively, 648 ± 219 μm at 1 day, 640 ± 204 μm at 1 week, 628 ± 212 μm at 1 month, and 632 ± 210 μm at 3 months postoperatively (P = .0009, with all postoperative vaulting measurements statistically similar to each other, but significantly different from the intraoperative measurement). However, intraoperative ICL vaulting had high predictability of postoperative vaulting at 3 months with r = 0.81 (P < .0001), and Bland-Altman analysis demonstrates a relatively constant difference between the 2 measurements as plotted against their mean with a bias of 98.27 μm and tight 95% limits of agreement range., Conclusions: Intraoperative ICL vaulting measured by OCT correlated highly with postoperative OCT vaulting and can be considered a reliable tool to predict the final ICL vault.

Purpose: To analyze the implications of different reference points on the read-out of epithelial thickness mapping., Methods: A simulation for changing the reference point from normal-to-the-surface tangent to parallel vertical sections quantifying its effect on the read-out of epithelial thickness mapping has been developed. The simulation includes a simple modeling of corneal epithelial profiles and allows the analytical quantification of the differences in the read-out from normal-to-the-surface tangent to parallel vertical sections epithelial thickness mapping., Results: The difference in the read-out between parallel vertical sections and normal-to-the-surface tangent epithelial thickness mapping increases for steeper corneas, but it is not largely affected by asphericity. The difference increases for thicker epithelia., Conclusions: The reference point for determining the readout of epithelial thickness mapping should be taken into account when interpreting output. Using conventional epithelial thickness map readings (normal-to-the surface tangent) in transepithelial ablations (representing close to parallel vertical sections) may result in induced refractive errors that can be quantified using simple theoretical simulations, because the center-to-periphery progression of the corneal epithelial profile deviates from the progression of the ablated one. Adjustments for the epithelial thickness read-out or, alternatively, for the target sphere can be easily derived. [J Refract Surg. 2020;36(2):200-207.]., (Copyright 2020, SLACK Incorporated.)

Purpose: To evaluate the tomographic and refractive characteristics of pediatric first-degree relatives of patients with keratoconus., Design: Cross-sectional study., Methods: Setting: Department of Ophthalmology at the American University of Beirut Medical, Beirut, Lebanon., Study Population: Pediatric first-degree relatives of patients with keratoconus. Both eyes of all participants aged between 6 and 18 years were included and studied., Exclusion Criteria: Soft contact lens use in the past 2 weeks or rigid gas-permeable lens wear within 4 weeks, history of prior ocular surgery or infectious keratitis, and unreliable corneal tomography. Masking and Randomization: Two masked cornea and refractive surgeons of different training backgrounds independently evaluated the participants' tomographic outputs. Additionally, the tomographic data were analyzed using Smadja's decision tree., Observation Procedures: Scheimpflug tomography, manifest refraction, and slit-lamp examination., Main Outcome Measures: Anterior curvature indices, posterior elevation values, thinnest pachymetry, and subjective and objective tomographic interpretation., Results: One hundred eighty-three subjects were recruited. Tomographic evaluation after Cohen's kappa coefficient analysis revealed 32 patients as having keratoconus (17.5%), while 35 patients (19.1%) were labeled as keratoconus by objective analysis. There were 11.5%-15.5% of patients with keratoconus aged less than 11 years, 18.0% aged 12-15 years, and 25.5% aged 16-18 years. Their respective steepest anterior curvature and thinnest pachymetry are 44.8 ± 6.5 diopters (D) and 515.9 ± 39.2 μm, 47.34 ± 3.4 D and 496.1 ± 37.9 μm, and 49.7 ± 6.1 D and 486.0 ± 66.5 μm. A total of 37.5% of the keratoconus patients were unilateral as evaluated by tomography alone., Conclusions: The prevalence of keratoconus in pediatric first-degree relatives of diagnosed keratoconus patients is high. Screening in this high-risk group is warranted., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Purpose: To describe an original technique to unfold the graft in vitrectomized eyes undergoing Descemet membrane endothelial keratoplasty (DMEK)., Methods: We performed a retrospective chart and video review of successive cases presenting with corneal decompensation in vitrectomized eyes or aphakic eyes in which DMEK or combined DMEK/scleral-fixated intraocular lens implantation was indicated and in which a specific technique [Cornea-Press (C-Press)] was used to unfold the graft. C-Press is characterized by corneal indentation intended to artificially shallow the anterior chamber and allow the graft to unroll. Best spectacle-corrected visual acuity, central corneal thickness, the time of graft unfolding, endothelial cell count, and the incidence of intraoperative/postoperative complications were analyzed., Results: Eleven eyes of 11 patients (8 men, mean age: 73 ± 12 years) were included. Corrected distance visual acuity (logarithm of the minimum angle of resolution) improved from 1.44 ± 0.23 preoperatively to 0.77 ± 0.36 6 months postoperatively (P < 0.001). Central corneal thickness (CCT) decreased from 644 ± 79 preoperatively to 516 ± 49 μm 6 months postoperatively. The graft unfolding time was 4.4 ± 2.5 minutes. Mean endothelial cell density was 2762 ± 192 preoperatively and 1872 ± 324 cells/mm 6 months postoperatively. No eye showed intraoperative complications. Rebubbling for partial detachment was needed in 2 cases (18%)., Conclusions: The C-Press technique enables likely safe and reproducible DMEK surgery in vitrectomized eyes. Further clinical studies with a large number of patients and longer follow-up are required to confirm our preliminary results.

Purpose: To evaluate the role of a novel automated detection software as compared to human operators in assessing the presence and depth of stromal demarcation line on optical coherence tomography (OCT) in keratoconus eyes post cross-linking., Design: Reliability analysis study., Methods: Two independent operators and an automated detection software examined corneal OCTs of 25 eyes of 25 patients post corneal cross-linking using the Dresden protocol, at 3 months postoperatively. Operators evaluated the presence of the demarcation line and measured its depth by looking at OCT images (128 cuts) on 2 separate occasions 1 week apart. The automated software examined all 128 cuts of each OCT measurement., Results: The mean corneal demarcation line depth was 321.54 ± 47.71, 322.86 ± 45.77, and 309.21 ± 40.98 μm, as computed by the automated detection software and the human operators, respectively. The intraclass correlation coefficients (ICC) between the automated detection software and Observers #1 and #2 were 0.884 and 0.847, respectively (P < .001). The ICC for interoperator reproducibility was 0.890, and for intraoperator repeatability for Operator #1 and Observer #2 were 0.922 and 0.925, respectively. The ICC for intersoftware repeatability was 1. Bland-Altman plots showed a good agreement between both observers and the software, with adequate 95% limits of agreement., Conclusion: Detection of the demarcation line by human operators is repeatable and reproducible, but it can be further optimized and standardized by an ultrafast and accurate automated software detection tool, providing a reliable indicator for treatment success., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Purpose: To evaluate a proposed technology for offering objective grading and mapping of corneal haze as detected by corneal spectral domain optical coherence tomography after corneal cross-linking., Methods: This was a retrospective study to evaluate corneal optical coherence tomography images performed on 44 eyes of 44 patients who underwent corneal cross-linking between January 2014 and May 2015, at the American University of Beirut Medical Center., Results: Overall average brightness of the cornea was markedly increased from 43.4% (±6.0) at baseline to 50.2% (±4.4) at 1 month, 47.9% (±4.4) at 3 months, and 46.4% (±5.7) at 6 months with P <0.001, <0.001, and 0.005, respectively. In the anterior stroma, the average brightness significantly increased at 1, 3, and 6 months with values of 54.8% (±3.9), 52.5% (±5.2), and 49.7% (±6.9) with P <0.001, <0.001, and 0.003, respectively. In the mid stroma, the change was clinically significant at 1 and 3 months, whereas in the posterior stroma, it was only significant at 1 month compared with baseline (P = 0.003). Overall, haze was mostly present at 1 month after surgery in all regions, especially in the anterior (32.1%; ±19.2) and mid stromal regions (9.1%; ±18.8), P <0.001 and 0.001, respectively. In contrast, haze in the posterior stromal region peaks at 3 and 6 months after surgery., Conclusions: Anterior stromal haze was the greatest in intensity and area and it was present for a longer time span than mid and posterior stromal haze. At 12 months, the anterior stroma had still more haze intensity than preoperatively. This image-based software can provide objective and valuable quantitative measurements of corneal haze, which may impact clinical decision-making after different corneal surgeries.

Purpose: To evaluate the epithelial erosion incidence and refractive results in myopic eyes undergoing single-step transepithelial photorefractive keratectomy (TransPRK) compared with alcohol-assisted photorefractive keratectomy (PRK)., Methods: This was a retrospective nonrandomized comparative study conducted at the American University of Beirut Medical Center. A total of 189 eyes that had undergone single-step transepithelial PRK (TransPRK) were compared with 189 matched eyes that had undergone alcohol-assisted PRK over a follow-up of 1 year. The incidence and symptoms of epithelial erosion were evaluated in both treatment groups using a post hoc questionnaire administered to patients selected in the study. Visual and refractive outcomes, including vector analysis of astigmatism, and corneal higher-order aberrations were also compared at 1-year postoperatively., Results: Baseline characteristics were similar between 2 groups (P > 0.05). A slight difference was detected at 12-month follow-up in the refractive cylinder (P = 0.02) and difference vector (P = 0.01) between eyes that had undergone TransPRK versus alcohol-assisted PRK. All other visual and refractive outcomes were similar at 12-month follow-up between both groups. Of note, 9.9% of patients with alcohol-assisted PRK (10/101) reported to the clinic because of tearing and stabbing sensation within 1 week after contact lens removal as opposed to 1% (1/100) of the TransPRK group (P = 0.0097). Subclinical recurrent epithelial erosion symptoms occurred more frequently in alcohol-assisted PRK: soreness to touch, sharp pains, and eyelid sticking occurred in 26.0% versus 6.6%, 32.5% versus 7.9%, and 26.0% versus 6.6% among the patients who were treated with alcohol-assisted PRK versus those who were treated with TransPRK, respectively (P ≤ 0.002)., Conclusions: Single-step TransPRK for myopic eyes yields refractive results similar to those of alcohol-assisted PRK but shows a lesser incidence of early postoperative epithelial erosions and subsequent subclinical recurrent erosions.

Background/aims: To evaluate refractive outcomes of single-step transepithelial photorefractive keratectomy (TransPRK) versus alcohol-assisted PRK (EtOH-PRK) for the correction of high myopia., Methods: This was a retrospective non-randomised comparative study conducted at the American University of Beirut Medical Center, Beirut, Lebanon. Eyes with myopia (spherical equivalent (SE) larger than -6.00 D) that had undergone EtOH-PRK treatment combined with mitomycin C and TransPRK (SE: -7.53±0.90 D and -7.24±0.77 D, p=0.062), using the Schwind Amaris excimer laser, were included. 59 eyes (37 patients) that had single-step TransPRK were compared with 59 eyes (36 patients) that had EtOH-PRK. Visual and refractive outcomes, including analysis of astigmatism, and corneal higher order aberrations (HOAs) at 6.0 mm optical zone, were compared for 12 months postoperatively., Results: Baseline characteristics were similar between the two groups (p>0.05). The SE deviation from target (SEDT) at 1 week, 1, 3, 6 and 12 months follow-up visits were similar between groups (p=0.428). At 12 months, 81.3% and 73.3% of eyes that had undergone TransPRK and EtOH-PRK, respectively, were between ±0.50 D SEDT (p=0.381). Mean cylinder power was 0.33±0.26 D versus 0.41±0.30 D at 12 months follow-up (p=0.140). The mean success index was 0.50±0.50 for the TransPRK group and 0.49±0.52 for the EtOH-PRK group (p=0.939), while the absolute mean angle of error was 7.81°±61.98° vs 13.12°±71.86° (p=0.667), respectively. The change in total, spherical and comatic corneal HOAs were similar in both groups at 12 months (p>0.05). Haze was similar between both groups; two eyes had +1 haze at 12 months in the TransPRK group versus zero eyes among the EtOH-PRK group (p=0.154)., Conclusions: Single-step TransPRK for high myopia with or without astigmatism appears to yield similar visual, refractive and safety results as EtOH-PRK., Competing Interests: Competing interests: SAM is an employee of Schwind Eye-Tech Solutions., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

A 27-year-old woman had microkeratome-assisted laser in situ keratomileusis (LASIK) for moderate bilateral hyperopia. The preoperative ophthalmologic examination was unremarkable except for minimal lissamine green staining bilaterally on the nasal conjunctiva. On the first postoperative day, the uncorrected distance visual acuity (UDVA) was 20/20 bilaterally and the corneas were clear. Four days later, the patient presented with mild blur in both eyes. Examination showed diffuse bilateral epithelial cysts encompassing the central 6.0 to 7.0 mm of the flaps with overlying diffuse lissamine green staining. The UDVA was 20/30 bilaterally. Aggressive lubrication was administered. The epithelial cysts coalesced into larger ones over subsequent visits and began regressing over several months, along with improvement in vision. At 6 months, the cysts had completely resolved, the corneas were clear, and the UDVA was 20/20., (Copyright © 2017 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Twenty-one months after successful small-aperture corneal inlay (Kamra) implantation simultaneous with myopic laser in situ keratomileusis, a patient presented with a superior rhegmatogenous macula-involving retinal detachment. Successful pars plana vitrectomy, transscleral cryotherapy, and gas tamponade were performed with the inlay in situ. Three months later, uneventful phacoemulsification and posterior chamber intraocular lens implantation were performed, also with the inlay in situ, for a visually significant cataract. Visualization of the central and peripheral retina and the anterior segment was possible in both procedures through the central aperture and around the periphery of the inlay. An indirect noncontact visualization system was helpful in the retinal surgery, and rotating the eye was helpful in both surgeries if the inlay blocked visualization., (Copyright © 2017 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To assess central corneal thickness (CCT) and corneal haze in keratoconus eyes following corneal cross-linking (CXL)., Design: Prospective noncomparative case series., Methods: Forty patients (44 eyes) with keratoconus that had serial evaluation for CCT, following CXL, using high-definition optical coherence tomography (HD-OCT), ultrasound pachymetry (USP), and dual Scheimpflug tomography. CCT was measured at baseline, then at 2 weeks and 1, 3, 6, and 12 months postoperatively., Results: The mean baseline CCT measurements were 470.02 μm, 469.79 μm, and 466.66 μm using the HD-OCT, the USP, and dual Scheimpflug tomography, respectively (P = .91). Following CXL, the mean CCT measurements by dual Scheimpflug, at all follow-up periods, were lower compared to mean baseline reading (P < .003). The mean CCT measurements by the HD-OCT and USP were similar to baseline readings except for the thicker readings at the 2-week follow-up visit. Overall, the mean CCT obtained by the USP was similar to that obtained by the HD-OCT throughout the 12-month period. However, the mean CCT measurements obtained by dual Scheimpflug tomography were statistically and clinically significantly lower than those obtained by both HD-OCT and USP at all follow-up visits., Conclusions: USP and HD-OCT showed better agreement in CCT readings at all visits, and may better estimate the true CCT following CXL as compared to dual Scheimpflug tomography. The lower mean CCT post-CXL as measured by the latter seems to be correlated with the amount of haze that develops after cross-linking., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Purpose: To evaluate and compare the refractive predictability and stability of laser in situ keratomileusis (LASIK) flap creation performed with a femtosecond laser and with a mechanical microkeratome to correct mild to moderate hyperopia., Setting: American University of Beirut Medical Center, Beirut, Lebanon., Design: Retrospective case series., Methods: Patients who had hyperopic LASIK treatment using the Amaris excimer laser were included. Eyes in which the LDV femtosecond laser was used for flap creation were compared with eyes in which the Moria M2 microkeratome was used., Results: The microkeratome group comprised 53 eyes and the femtosecond laser group, 72 eyes. Baseline characteristics were similar between groups (P > .05). The mean spherical equivalent (SE) deviation from target 1 week postoperatively was -0.08 diopter (D) ± 0.58 (SD) in the femtosecond laser group and -0.06 ± 0.87 D in the microkeratome group (P = .92). Thereafter, the mean SE deviation from target increased gradually and by 6 months postoperatively was +0.30 ± 0.50 D and +0.70 ± 0.71 D, respectively (P = .001). The correlation between the achieved and the attempted SE refraction was better in the femtosecond laser group (R(2) = 0.806) than the microkeratome group (R(2) = 0.671)., Conclusions: Using the same nomogram, the short-term refractive outcomes of hyperopic LASIK with flap creation performed with the femtosecond laser were comparable to those for the microkeratome; however, the femtosecond group showed significantly better stability over the 6-month follow-up and better predictability, as reflected by a lower standard deviation and stronger Pearson correlation., Financial Disclosure: Dr. Arba Mosquera is an employee of Schwind eye-tech-solutions GmbH and Co. KG. No other author has a financial or proprietary interest in any material or method mentioned., (Copyright © 2015 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate the efficacy and safety of a single intrastromal corneal ring segment (ICRS) (450 μm Intacs SK) in moderate to severe keratoconic eyes with an inferiorly located cone and a noninvolved center., Setting: Ophthalmology Department, American University of Beirut Medical Center, Beirut, Lebanon., Design: Retrospective case series., Methods: The uncorrected (UDVA) and corrected (CDVA) distance visual acuities, central and inferior maximum topographic keratometry (K) values, manifest cylinder, and spherical equivalent (SE) were recorded preoperatively and 1 week and 1, 3, and 6 months postoperatively., Results: Thirty eyes were studied. The mean age was 29.6 years ± 8.0 (SD). The mean preoperative UDVA and CDVA were 20/86 and 20/42, respectively. The mean center K was 49.14 ± 4.39 diopters (D); the mean maximum K, 56.78 ± 6.02 D; and the mean center K - maximum K, -7.45 ± 5.61 D. The mean SE and cylinder were -2.24 ± 2.32 D and -4.33 ± 1.43 D, respectively, with sphere ranging from +2.00 to -18.00 D. At 6 months, the UDVA improved to 20/32. The mean SE was -1.02 ± 2.04 D (P = .0330); the mean cylinder, -1.67 ± 1.00 D (P < .00); and the mean center K - maximum K, -4.92 ± 4.36 D (P < .05). The CDVA improved more than 2 lines; no eye lost any lines. Topographic indices improved in all eyes., Conclusions: Single ICRS implantation in eyes with moderate to severe keratoconus and inferiorly located cones was safe and effective. The development of a nomogram relying more on topographic data is suggested., Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned., (Copyright © 2015 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To assess the efficacy and safety of early one-step transepithelial photorefractive keratectomy (PRK) with mitomycin C as treatment for buttonhole formation during LASIK., Methods: Eight patients who developed a buttonhole during LASIK with mechanical or femtosecond flap creation underwent one-step transepithelial PRK a few days after the formation of the buttonhole. The re-treatment procedure was performed after complete epithelial healing and smooth epithelial fluorescein profile were ensured. Postoperative manifest refraction, uncorrected and corrected distance visual acuity, and haze formation were assessed during 6 months of follow-up., Results: Mean duration of the re-treatment procedure after buttonhole formation was 5 days (range: 4 to 7 days). Mean manifest refractive spherical equivalent and cylinder refraction were -0.05 ± 0.18 and -0.18 ± 0.22 diopters, respectively, at 6 months postoperatively. Uncorrected distance visual acuity was 20/20 in all patients after 3 months of follow-up. No haze formation was detected., Conclusions: Early one-step transepithelial PRK with mitomycin C seems to be a safe and effective treatment for LASIK buttonhole complication., (Copyright 2015, SLACK Incorporated.)

Purpose: The Boston keratoprosthesis (KPro) is the most commonly used KPro worldwide. There are limited data on the outcomes when irradiated corneas are used as KPro carriers. We report a retrospective analysis of corneal transplantations performed in a regular surgical mission setting in Beirut, Lebanon, using the Boston KPro type 1 and gamma-irradiated carrier corneas, and we describe visual outcomes, complications, and retention percentage., Methods: We conducted a retrospective analysis of 17 consecutive eyes from 16 patients who underwent Boston KPro type 1 implantation at the Beirut Eye Specialist Hospital between December 2010 and July 2012. Patient medical records were reviewed for preoperative, intraoperative, and postoperative details., Results: Postoperatively, 9 (52.9%), 5 (29.4%), and 2 (11.7%) eyes had a corrected visual acuity of 20/400 or better, 20/100 or better, and 20/40 or better, respectively, at the most recent follow-up visit. A total of 16 eyes (94.1%) improved in corrected visual acuity over the course of follow-up. Overall, 13 eyes (76.4%) developed at least 1 complication after surgery. Retroprosthetic membrane formation was the most common complication, occurring in 10 eyes (58.8%). Neither infectious keratitis nor corneal stromal necrosis was noted during the follow-up period. The retention percentage was 94.1%., Conclusions: The visual acuity outcomes, incidence of complications, and retention percentage of the KPro using gamma-irradiated carrier corneas are comparable with the outcomes of KPro implantation reported in the literature using fresh grafts as carriers. KPro with irradiated corneal carrier grafts seems to be an effective option to increase the supply of transplantation suitable corneas in remote areas, where fresh corneal grafts may be scarce.

Purpose: To assess the agreement between the elevation and curvature measurements of the anterior and posterior corneal surfaces obtained using the Galilei Dual Scheimpflug Analyzer and those obtained using the Pentacam single Scheimpflug system., Methods: This prospective, noninterventional, diagnostic study was conducted at the Department of Ophthalmology at the American University of Beirut (Medical Center) and included 60 eyes of 60 consecutive patients. Measurements were obtained using 2 different Scheimpflug analyzers (Galilei and Pentacam). The best-fit sphere was set at 8 mm in both machines. Pachymetry (CCT), anterior elevation (AE) and posterior elevation (PE), and curvature were assessed. Pearson's correlation coefficients, comparison of means, and Bland-Altman plots were used to evaluate agreement between the 2 systems., Results: The average CCT (at the corneal apex) was 533 ± 35 µm and 532 ± 37 µm (p=0.980), the average central AE was 1.25 ± 3.95 µm and 2.29 ± 5.28 µm (p=0.964), and the average central PE was 4.19 ± 8.18 µm and 5.42 ± 14.05 (p=0.956) µm with the Galilei and Pentacam, respectively., Conclusion: The Scheimpflug analyzers correlated well in the assessment of pachymetry, elevation, and curvature.

Background/aims: To analyse the refractive implications of single-step, transepithelial photorefractive keratectomy (TransPRK) ablations., Methods: A simulation for quantifying the refractive implications of TransPRK ablations has been developed. The simulation includes a simple modelling of corneal epithelial profiles, epithelial ablation profiles as well as refractive ablation profiles, and allows the analytical quantification of the refractive implications of TransPRK in terms of wasted tissue, achieved optical zone (OZ) and induced refractive error., Results: Wasted tissue occurs whenever the actual corneal epithelial profile is thinner than the applied epithelial ablation profile, achieved OZ is reduced whenever the actual corneal epithelial profile is thicker than the applied epithelial ablation profile and additional refractive errors are induced whenever the actual difference centre-to-periphery in the corneal epithelial profile deviates from the difference in the applied epithelial ablation profile., Conclusions: The refractive implications of TransPRK ablations can be quantified using simple theoretical simulations. These implications can be wasted tissue (∼14 µm, if the corneal epithelial profile is thinner than the ablated one), reduced OZ (if the corneal epithelial profile is thicker than ablated one, very severe for low corrections) and additional refractive errors (∼0.66 D, if the centre-to-periphery progression of the corneal epithelial profile deviates from the progression of the ablated one). When TransPRK profiles are applied to normal, not previously treated, non-pathologic corneas, no specific refractive implications associated to the transepithelial profile can be anticipated; TransPRK would provide refractive outcomes equal to those of standard PRK. Adjustments for the planned OZ and, in the event of retreatments, for the target sphere can be easily derived.

Purpose: To evaluate the effect of the double-K (DK) modification on third-generation formulas., Methods: Thirty-eight previously myopic and 24 previously hyperopic eyes that underwent phacoemulsification with intraocular lens (IOL) insertion after Laser in situ keratomileusis (LASIK) were evaluated. Pre-LASIK refraction and keratometry, post-LASIK topography, axial length (AL), IOL type and power, and 1-month postphacoemulsification refraction were recorded spherical equivalent after phacoemulsification (SE(postphaco)). Measured corneal power was adjusted using published and validated methods for postmyopic and posthyperopic LASIK. For each eye, and using SE(postphaco), different DK-IOL formulas were used to calculate the corresponding IOL power, the outcome measure, which was compared with the implanted IOL., Results: DK-Holladay 1 yielded the highest Pearson correlation coefficient (PCC), 0.955 for myopes and 0.943 for high myopes (AL>26 mm). Mean error (ME) and mean absolute error (MAE) for myopes for DK Sanders-Retzlaff-Kraff theoretical formula [DK-SRK/T] were 0.44±0.84 D and 0.75±0.61 D for DK-SRK/T compared with -0.04±0.67 D and 0.52±0.40 D for DK-Holladay 1 (P<0.001 and P=0.016, respectively), and 0.03±0.88 and 0.64±0.58 for DK-Hoffer Q. For high myopes, ME and MAE were 0.75±0.81 D and 0.84±0.69 D for DK-SRK/T, and -0.05±0.74 D (P<0.0001) and 0.57±0.45 D (P=0.019) for DK-Holladay 1. About 29% of DK-SRK/T eyes with large AL had MAE>1.5 D, compared with 0% for DK-Holladay 1 and 14% for DK-Hoffer-Q. Eyes with previous hyperopic LASIK faired similarly for all formulas, with similar PCCs, and only 8% in each category with MAE>1.5 D., Conclusions: DK-SRK/T overestimates IOL power in eyes with large AL, especially with concomitant steep pre-lasik keratometry. Among third-generation formulas, DK-Holladay 1 seems more accurate to use in postmyopic LASIK eyes.

We present a case of fulminant panuveitis following iris suture fixation of a posterior chamber intraocular lens. We hypothesize that the zonular dehiscence allowed the inflammatory cells in the anterior compartment to gain access to the posterior segment mimicking endophthalmitis or toxic anterior segment syndrome. Also certain bulky lens designs, like the current Rayner hydrophilic acrylic lens, are difficult to manipulate and hold in the optic capture position, and hence the iris fixation of these lenses can be traumatic and lengthy. It is advised to exchange such lenses with 3-piece intraocular lenses that are easy to fixate.