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Purpose: Artificial tears only provide transient relief for dry eye. To the best of our knowledge, this is the first study to objectively compare treatment with artificial tears with Keratograph 5M, which allows accurate and objective investigation of dry eye and artificial tear treatment. We aimed to evaluate whether a preservative-free combination of 0.4% hyaluronic acid and 0.2% galactoxyloglucan can improve dry eye using the new topographer, Keratograph 5M. Patients and Methods: This prospective longitudinal, single-arm interventional cohort study was performed at a tertiary referral center and involved 20 patients with dry eye (40 eyes). Preservative-free artificial tears were administered every 3 h. The participants under went clinical and instrumental evaluations at baseline, 15, 30, 60, 90 and 120 min after instillation and 1 week and 1 month after treatment. Baseline values were considered as the controls. All patients were assessed with Keratograph 5M for non-invasive Keratograph first break-up time and non-invasive Keratograph average break-up time, conjunctival hyperemia, and tear meniscus height. Ocular surface staining with fluorescein was evaluated using the slit-lamp and fluorescein break-up time examinations, and the Ocular Surface Disease Index score was recorded for each patient. Results: The signs and symptoms improved after 1 month of preservative-free 0.4% hyaluronic acid and 0.2% galactoxyloglucan treatment. There was a significant increase in the non-invasive Keratograph first break-up time and non-invasive Keratograph average break-up time at 15, 30, 60, and 90 min, and 1 week and 1 month (P < 0.05) and a decrease in hyperemia, corneal staining, and Ocular Surface Disease Index scores after 1 week and 1 month (P < 0.05). No treatment-related adverse event was observed. Conclusion: A combination of 0.4% hyaluronic acid and 0.2% galactoxyloglucan artificial tears seems effective for treating dry eye. Keratograph 5M can objectively detect these

La COVID-19 (enfermedad por coronavirus 2019) nos plantea nuevos retos en nuestra rutina diaria. La última cifra publicada de sanitarios contagiados –se dejó de publicar por última vez el 18 de mayo– fue de 51,090 en total y 152 casos nuevos ese mismo día1. Por ello, debemos aprender a protegernos para continuar con nuestra rutina diaria quirúrgica lo más cercana a la normalidad preexistente.

Patients with severe limbal damage and limbal stem cell deficiency are a therapeutic challenge. We evaluated four decellularization protocols applied to the full-thickness and half-thickness porcine limbus, and we used two cell types to recellularize the decellularized limbi. The results demonstrated that all protocols achieved efficient decellularization. However, the method that best preserved the transparency and composition of the limbus extracellular matrix was the use of 0.1% SDS applied to the half-thickness limbus. Recellularization with the limbal epithelial cell line SIRC and human adipose-derived mesenchymal stem cells (hADSCs) was able to generate a stratified epithelium able to express the limbal markers p63, pancytokeratin, and crystallin Z from day 7 in the case of SIRC and after 14–21 days of induction when hADSCs were used. Laminin and collagen IV expression was detected at the basal lamina of both cell types at days 14 and 21 of follow-up. Compared with control native limbi, tissues recellularized with SIRC showed adequate picrosirius red and alcian blue staining intensity, whereas limbi containing hADSCs showed normal collagen staining intensity. These preliminary results suggested that the limbal substitutes generated in this work share important similarities with the native limbus and could be potentially useful in the future.

[Purpose]: Artificial tears only provide transient relief for dry eye. To the best of our knowledge, this is the first study to objectively compare treatment with artificial tears with Keratograph 5M, which allows accurate and objective investigation of dry eye and artificial tear treatment. We aimed to evaluate whether a preservative-free combination of 0.4% hyaluronic acid and 0.2% galactoxyloglucan can improve dry eye using the new topographer, Keratograph 5M. [Patients and Methods]: This prospective longitudinal, single-arm interventional cohort study was performed at a tertiary referral center and involved 20 patients with dry eye (40 eyes). Preservative-free artificial tears were administered every 3 h. The participants underwent clinical and instrumental evaluations at baseline, 15, 30, 60, 90 and 120 min after instillation and 1 week and 1 month after treatment. Baseline values were considered as the controls. All patients were assessed with Keratograph 5M for non-invasive Keratograph first break-up time and non-invasive Keratograph average break-up time, conjunctival hyperemia, and tear meniscus height. Ocular surface staining with fluorescein was evaluated using the slit-lamp and fluorescein break-up time examinations, and the Ocular Surface Disease Index score was recorded for each patient. [Results]: The signs and symptoms improved after 1 month of preservative-free 0.4% hyaluronic acid and 0.2% galactoxyloglucan treatment. There was a significant increase in the non-invasive Keratograph first break-up time and non-invasive Keratograph average break-up time at 15, 30, 60, and 90 min, and 1 week and 1 month (P < 0.05) and a decrease in hyperemia, corneal staining, and Ocular Surface Disease Index scores after 1 week and 1 month (P < 0.05). No treatment-related adverse event was observed. [Conclusion]: A combination of 0.4% hyaluronic acid and 0.2% galactoxyloglucan artificial tears seems effective for treating dry eye. Keratograph 5M can objectively detec

Purpose: In limbal stem cell deficiency, both the Ocular Surface Disease Index (OSDI) questionnaire and tear break-up time (BUT) are comparable between traditional methods and the Keratograph 5M. In this study, we aimed to correlate OSDI with Keratograph 5M interviewed OSDI, as well as slit-lamp tear BUT with Keratograph 5M noninvasive tear break-up time (NIKBUT) in limbal stem cell deficiency. Patients and methods: Thirty-eight limbal stem cell-deficiency patients (76 eyes) from Virgen Macarena-Rocio Hospital (Seville, Spain) underwent this diagnostic test study. All patients completed the traditional OSDI. We measured the BUT, performed a Keratograph 5M analysis of NIKBUT first (employed for the analysis) followed by the average NIKBUT, the level of dryness, and conducted the OSDI questionnaire through an interview. For each pair of tests, we analyzed the means and applied an intraclass correlation coefficient (r), creating a Bland-Altman plot for data dispersion. Results: Average values were 47.5 points (±25.8), and 47.3 points (±27.5) for traditional OSDI and Keratograph OSDI, respectively (P =0.87); the r value indicates good agreement (0.72). The Bland-Altman plot followed a linear pattern, and the results were similarly distributed. The NIKBUT mean was shorter than the BUT mean (P = 0.007); the r value indicates moderate agreement (0.574). The Bland-Altman plot formed an almost horizontal line, with almost all values between the mean and two standard deviations. Conclusion: Keratograph 5M is useful for the evaluation of the ocular surface in limbal stem cell deficiency. NIKBUT can substitute BUT based on its advantages of being non- invasive, objective, with intraobserver and interobserver repeatability and reliability. The Keratograph 5M OSDI is comparable to the traditional questionnaire.

Background/aims: Limbal stem cell deficiency (LSCD) is characterised by a marked decrease in limbal stem cells. It is classified primarily using subjective slit-lamp observations. In vivo confocal microscopy (IVCM) can non-invasively provide objective information on the condition of the limbal niche, the corneal epithelial basal cell density and the corneal sub-basal nerve plexus density (SND). We here used IVCM to evaluate changes in SND to improve LSCD classification. Methods: We evaluated and classified 38 patients (76 eyes, 44 with LSC and 32 control eyes) using the Rama, López-García and Deng (clinical and confocal) classifications and evaluated the concordance of the confocal and clinical classifications. We constructed a logistic regression model using multivariate analysis to correlate different degrees of conjunctivalisation with IVCM parameters and used receiver operating characteristic (ROC) curve analysis to establish the SND cut-off value with maximum diagnostic sensitivity and specificity. Results: The classification systems correlated moderately at best (kappa, 0.449). The corneal SND of cases (6469±6295 µm/mm2) was less (p<0.001) than in controls (20911±4142 µm/mm2). The SND, but not basal cell density, played a protective role against conjunctivalisation (OR, 0.069; 95% CI 0.008–0.619; p=0.01). An SND cut-off value of 17 215 µm/mm2 yielded a sensitivity and specificity of 95.5% and 90.6%, respectively, for LSCD diagnosis. Conclusion: The density of the corneal sub-basal nerve plexus was inversely related to conjunctivalisation in LSCD. Further studies are needed to verify this and to elucidate the directionality between these factors.

[Background/aims] Limbal stem cell deficiency (LSCD) is characterised by a marked decrease in limbal stem cells. It is classified primarily using subjective slit-lamp observations. In vivo confocal microscopy (IVCM) can non-invasively provide objective information on the condition of the limbal niche, the corneal epithelial basal cell density and the corneal sub-basal nerve plexus density (SND). We here used IVCM to evaluate changes in SND to improve LSCD classification. [Methods] We evaluated and classified 38 patients (76 eyes, 44 with LSC and 32 control eyes) using the Rama, López-García and Deng (clinical and confocal) classifications and evaluated the concordance of the confocal and clinical classifications. We constructed a logistic regression model using multivariate analysis to correlate different degrees of conjunctivalisation with IVCM parameters and used receiver operating characteristic (ROC) curve analysis to establish the SND cut-off value with maximum diagnostic sensitivity and specificity. [Results] The classification systems correlated moderately at best (kappa, 0.449). The corneal SND of cases (6469±6295 µm/mm2) was less (p<0.001) than in controls (20911±4142 µm/mm2). The SND, but not basal cell density, played a protective role against conjunctivalisation (OR, 0.069; 95% CI 0.008–0.619; p=0.01). An SND cut-off value of 17 215 µm/mm2 yielded a sensitivity and specificity of 95.5% and 90.6%, respectively, for LSCD diagnosis. [Conclusion] The density of the corneal sub-basal nerve plexus was inversely related to conjunctivalisation in LSCD. Further studies are needed to verify this and to elucidate the directionality between these factors.

INTRODUCCIÓN La Insuficiencia limbar (IL) es una enfermedad ocular debida a una disminución crítica de las células madre limbares encargadas de la renovación del epitelio corneal y de constituir una barrera entre el epitelio conjuntival, opaco, y el corneal, translúcido. Es conocida la relación entre el epitelio corneal y los nervios del plexo nervioso subbasal de la córnea, existiendo un circuito químico retroalimentado para su correcto trofismo. La ausencia de epitelio corneal sano y la neovascularización de la superficie corneal se relacionan con la ausencia de plexo nervioso corneal de forma recíproca. Se ha relacionado la disminución de la densidad de nervios del plexo nervioso corneal subbasal o sub-epitelial (Subbasal nerve density, SND) y de la densidad de células basales (Basal cell density, BCD) con estadios precoces de IL. HIPÓTESIS El análisis de la densidad celular y del plexo nervioso subbasal del epitelio corneal mediante la microscopía confocal ayuda al diagnóstico precoz y a clasificar la insuficiencia limbar basándonos en pruebas documentables y de forma no invasiva. MATERIAL Y MÉTODOS En nuestro trabajo, hemos analizado 97 ojos de 49 pacientes, de los cuales, 85 ojos estaban diagnosticados clínicamente de IL y el resto actuaron de control. Se les realizó exploración oftalmológica completa, incluyendo fotografías de polo anterior, tinciones vitales, escala de Oxford y Van Bijsterveld, test de OSDI y VFQ 25, análisis con Pentacam®, Keratograph 5M® (K5M) y microscopio confocal HRT II con módulo de córnea Rostock®. Se catalogó a cada paciente según las clasificaciones de Rama, López-García, Deng clínica, Deng confocal y Schwartz. Para el análisis estadístico se ha usado paquete estadístico SPSS 22 y para el tamaño muestral el nQuery Advisor Release 7. Para relacionar dos variables cualitativas se realizaron tablas de contingencia y luego, prueba Chi-Cuadrado o bien, los métodos no asintóticos de Montecarlo y prueba Exacta. Para la comparación de varia, INTRODUCTION Limbal stem cell deficiency (LSCD) is an eye disease caused by a critical decrease in limbal stem cells responsible for the renewal of the corneal epithelium and form a barrier to the conjunctival epithelium, opaque and vascularized epithelium. It is known the relationship between the corneal epithelium and neural subasal corneal nerve plexus, having a feedback circuit. The lack of healthy corneal epithelium and corneal neovascularization surface relates to the absence of corneal nerve plexus reciprocally. It has been associated with decreased density of the corneal nerve plexus nerves (SND) and basal cell density (BCD) with early stages of IL. HYPOTHESIS Analysis of cell density and subasal corneal epithelial nerve plexus using confocal microscopy help to early diagnosis and classify LSCD based on documentable and non-invasive tests. MATERIAL AND METHODS In our work, we have analyzed 97 eyes of 49 patients, of whom 85 eyes were diagnosed clinically and the rest of IL acted as controls. They underwent complete eye examination, including photographs of the anterior pole, vital stains, Oxford and Van Bijsterveld scales, OSDI and VFQ 25 questionnaires, Pentacam® tomography, Keratograph 5M® (K5M) and HRT II confocal microscopy with Rostock® cornea module. We classified these patients through Rama, Lopez-Garcia, Deng clinic, confocal Deng and Schwartz classifications. SPSS 22 was used for statistical analysis and nQuery Advisor Release 7 for sample size. To make the ordered logistic regression model, multivariate analysis was done by a non-automated method of direct introduction of variables, measuring the reliability with Hosmer-Lemeshow index. Agreement of classifications was measured through Cohen's kappa coefficient. RESULTS SND was analyzed with confocal microscopy in patients with IL: 6469 (6295) microns / mm2; lower than our healthy controls, 21766 (4970) microns / mm2) and reference numbers described in the literature,19000 microns/ mm2 (p <0.0005).