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The general physician as well as the medical specialist may be confronted with a patient with one or two red eyes. To be adequately equipped we answer a series of questions on diagnosis, treatment and referral of patients with red eyes after trauma, or with conjunctivitis, keratitis, scleritis, uveïtis, endophthalmitis or acute glaucoma. Refer to an ophthalmologist or not?

Introduction: Allogeneic serum from blood donors is starting to be used to treat patients with dry eye disease (DED). However, the optimal dose is not known. We therefore aimed to evaluate the clinical efficaciousness and user-friendliness of micro-sized versus conventional-sized allogeneic serum eye drops (SEDs)., Methods: In a randomized trial, patients with DED first receive micro-sized SEDs (7 µl/unit) for 1 month, followed by a 1-month washout, before receiving conventional-sized SEDs (50 µl/unit) for 1 month; or vice versa. The primary endpoint was the Ocular Surface Disease Index (OSDI) score. Secondary endpoints were tear break-up time (TBT), tear production (TP), and presence of corneal punctate lesions (CP). The user-friendliness of both application systems was also compared. A linear mixed model for cross-over design was applied to compare both treatments., Results: Forty-nine patients completed the trial. The mean OSDI score significantly improved from 52 ± 3 to 41 ± 3 for micro-sized SEDs, and from 54 ± 3 to 45 ± 3 for conventional-sized SEDs. Non-inferiority (margin = 6) of micro-sized SEDs was established. We demonstrate a significant improvement for TBT in case of conventional-sized SEDs and for CP in both treatment groups. TP trended towards an improvement in both treatment groups. The user-friendliness of the conventional drop system was significantly higher., Conclusions: For the first time, non-inferiority of micro-sized allogeneic SEDs was established. The beneficial effect of both SED volumes was similar as measured by the OSDI score. Although user-friendliness of the micro drop system was significantly lower, it is an attractive alternative as it saves valuable donor serum., Trial Registration: ClinicalTrials.gov (NCT03539159)., (© 2023. The Author(s).)

Purpose: To evaluate the safety and efficacy of 360° circumferential trabeculotomy (TO) for steroid induced glaucoma (SIG) of short duration., Methods: Retrospective analysis of surgical results of 46 eyes of 35 patients undergoing microcatheter-assisted TO. All eyes had high intraocular pressure for at most about 3 years due to steroid use. Follow-up was between 2.63 and 47.9 months (mean 23.9, median 25.6)., Results: Intraocular pressure (IOP) before surgery was 30.8 ± 8.3 mm Hg, with 3.8 ± 1.0 pressure-lowering medications. After 1 to 2 years, mean IOP was 11.2 ± 2.6 mm Hg (n = 28); mean number of IOP-lowering medications was 0.9 ± 1.3. At their last follow-up, 45 eyes had an IOP < 21 mm Hg, and 39 eyes had an IOP < 18 mm Hg with or without medication. After 2 years, the estimated probability of having an IOP below 18 mm Hg (with or without medication) was 85 ± 6%, and the estimated probability of not using medication was 56 ± 7%. Steroid response was no longer present in all eyes receiving steroids after surgery. Minor complications consisted of hyphema, transient hypotony, or hypertony. One eye proceeded to receiving a glaucoma drainage implant., Conclusion: TO is particularly effective in SIG with relative short duration. This concurs with the pathophysiology of the outflow system. This procedure seems particularly suited for eyes for which target pressures in the mid-teens are acceptable, particularly when chronic use of steroids is necessary ., (© 2023. The Author(s).)

Myotonic dystrophy type 1 is a neuromuscular disorder affecting multiple organ systems and is characterized by a variety of clinical presentations. Anticipation leads to an earlier and more severe phenotype in subsequent generations. Early-onset cataract is a common initial manifestation of the late or adult-onset type of myotonic dystrophy 1. Due to its multicausal nature, early-onset cataract is often not recognized as a feature of this disease, leading to diagnostic delay resulting in consequences for successive generations, treatment and counseling. A qualitative study with semi-structured interviews was performed with purposive sampling of eight participants with myotonic dystrophy type 1 and early-onset cataract to investigate the physical and psychosocial consequences experienced due to diagnostic delay. Prior to the early-onset cataract, all participants experienced other multisystem symptoms that could have been explained by myotonic dystrophy. The diagnostic delay had severe hereditary consequences: a subsequent generation with more severely affected (grand)children was born resulting in large emotional burden for the patients. To conclude, early-onset cataract is a warning sign and ophthalmologists play a crucial role in the early detection of myotonic dystrophy type 1 by recognizing this symptom and preventing the birth of severely affected children leading to emotional and psychosocial consequences., Competing Interests: Declaration of Competing interests The authors report no competing interests., (Copyright © 2022. Published by Elsevier B.V.)

Purpose: Primary congenital glaucoma (PCG) is a form of childhood glaucoma caused by maldevelopment of the anterior chamber. Disease severity differs greatly amongst patients. Ultrasound biomicroscopy (UBM) is a non-invasive technique that can visualize the anterior segment in infants in vivo. The purpose of this narrative review is to make an overview of the UBM data in PCG and study the applicability of UBM in characterizing the disease., Methods: An online search was performed on PubMed in December 2020. After a critical appraisal of the included articles, study and patient characteristics were summarized. The UBM measurements of the anterior segment in PCG of the different studies were analysed., Results: Six studies were included in this review. All were cross-sectional prospective studies. A total of 221 PCG eyes were examined. PCG eyes showed a larger trabecular iris angle, decreased iris thickness, narrower or absent Schlemm's canal and an increased zonular length compared to controls. Abnormal tissue membrane covering the trabecular meshwork and abnormal insertion of the iris and ciliary process were frequently found. The success rate of glaucoma surgery depended on the severity of anterior segment malformations found with UBM., Conclusion: Malformations of the anterior segment in PCG can be demonstrated by UBM in vivo. This imaging can help to characterize disease severity and might support surgical treatment decisions., (© 2021 The Authors. Acta Ophthalmologica published by John Wiley & Sons Ltd on behalf of Acta Ophthalmologica Scandinavica Foundation.)

Purpose: Serum eye drops (SEDs) are used to treat a variety of ocular surface defects. Serum eye drops (SEDs) are normally produced from the patient's blood. However, not all patients can donate sufficient or suitable blood, and logistics can be challenging. Allogeneic blood from voluntary blood donors does not have these disadvantages. Our aim was to evaluate whether autologous and allogeneic SEDs have comparable efficacy and tolerability., Methods: In a prospective, double-blind crossover trial, patients with severe dry eyes were randomized to first receive autologous SEDs for one month, followed by one-month washout, before receiving allogeneic SEDs for 1 month; or receive the SED preparations in reverse order. The Ocular Surface Disease Index (OSDI) was the primary endpoint, and various secondary endpoints were determined. A linear mixed model with random intercept for each patient was applied per treatment group to compare the pre- and postoutcome measurements., Results: Nineteen patients were enrolled, of whom 15 completed the trial. When autologous SEDs were used, the mean ± SD OSDI improved from 62 ± 19 to 57 ± 18. For allogeneic SEDs, the OSDI changed from 59 ± 20 to 56 ± 23. The estimated mean difference (95% confidence interval) was -4.2 (-9.5 to 1.2) for autologous and -4.5 (-9.8 to 0.9) for allogeneic SEDs (both, not significant). Adverse events were mild and resolved completely., Conclusion: Autologous and allogeneic SEDs have comparable efficacy and tolerability for use in patients with severe dry eyes. Allogeneic SEDs are therefore an attractive alternative for patients who need SEDs but are clinically or logistically unable to donate blood., (© 2021 The Authors. Acta Ophthalmologica published by John Wiley & Sons Ltd on behalf of Acta Ophthalmologica Scandinavica Foundation.)

Purpose: Compare patients treated for Retinopathy of Prematurity (ROP) in two consecutive periods., Methods: Retrospective inventory of anonymized neonatal and ophthalmological data of all patients treated for ROP from 2010 to 2017 in the Netherlands, subdivided in period (P)1: 1-1-2010 to 31-3-2013 and P2: 1-4-2013 to 31-12-2016. Treatment characteristics, adherence to early treatment for ROP (ETROP) criteria, outcome of treatment and changes in neonatal parameters and policy of care were compared., Results: Overall 196 infants were included, 57 infants (113 eyes) in P1 and 139 (275 eyes) in P2, indicating a 2.1-fold increase in ROP treatment. No differences were found in mean gestational age (GA) (25.9 ± 1.7 versus 26.0 ± 1.7 weeks, p = 0.711), mean birth weight (791 ± 311 versus 764 ± 204 grams, p = 0.967) and other neonatal risk factors for ROP. In P2, the number of premature infants born <25 weeks increased by factor 1.23 and higher oxygen saturation levels were aimed at in most centres. At treatment decision, 59.6% (P1) versus 83.5% (P2) (p = 0.263) infants were classified as Type 1 ROP (ETROP classification). Infants were treated with laser photocoagulation (98 versus 96%) and intravitreal bevacizumab (2 versus 4%). Retreatment was necessary in 10 versus 21 (p = 0.160). Retinal detachment developed in 6 versus 13 infants (p = 0.791) of which 2 versus 6 bilateral (p = 0.599)., Conclusion: In period 2, the number of infants treated according to the ETROP criteria (Type 1) increased, the number of ROP treatments, retinal detachments and retreatments doubled and the absolute number of retinal detachments increased. Neonatal data did not provide a decisive explanation, although changes in neonatal policy were reported., (© 2020 The Authors. Acta Ophthalmologica published by John Wiley & Sons Ltd on behalf of Acta Ophthalmologica Scandinavica Foundation.)

Introduction: Recognizing fungal keratitis based on the clinical presentation is challenging. Topical therapy may be initiated with antibacterial agents and corticosteroids, thus delaying the fungal diagnosis. As a consequence, the fungal infection may progress ultimately leading to more severe infection and blindness. We noticed an increase of fungal keratitis cases in the Netherlands, especially caused by Fusarium species, which prompted us to conduct a retrospective cohort study, aiming to describe the epidemiology, clinical management, and outcome. Materials and Methods: As fungi are commonly sent to the Dutch mycology reference laboratory for identification and in vitro susceptibility testing, the fungal culture collection was searched for Fusarium isolates from corneal scrapings, corneal swabs, and from contact lens (CL) fluid, between 2005 and 2016. All Fusarium isolates had been identified up to species level through sequencing of the ITS1-5.8S-ITS2 region of the rDNA and TEF1 gene. Antifungal susceptibility testing was performed according to the EUCAST microbroth dilution reference method. Antifungal agents tested included amphotericin B, voriconazole, and natamycin. In addition, susceptibility to the antisepticum chlorhexidine was tested. Ophthalmologists were approached to provide demographic and clinical data of patients identified through a positive culture. Results: Between 2005 and 2016, 89 cases of Fusarium keratitis from 16 different hospitals were identified. The number of cases of Fusarium keratitis showed a significant increase over time ( R 2 = 0.9199), with one case in the first 5 years (2005-2009) and multiple cases from 2010 and onwards. The male to female ratio was 1:3 ( p = 0.014). Voriconazole was the most frequently used antifungal agent, but treatment strategies differed greatly between cases including five patients that were treated with chlorhexidine 0.02% monotherapy. Keratitis management was not successful in 27 (30%) patients, with 20 (22%) patients requiring corneal transplantation and seven (8%) requiring enucleation or evisceration. The mean visual acuity (VA) was moderately impaired with a logMAR of 0.8 (95% CI 0.6-1, Snellen equivalent 0.16) at the time of Fusarium culture. Final average VA was within the range of normal vision [logMAR 0.2 (95% CI 0.1-0.3), Snellen equivalent 0.63]. CL wear was reported in 92.9% of patients with Fusarium keratitis. The time between start of symptoms and diagnosis of fungal keratitis was significantly longer in patients with poor outcome as opposed to those with (partially) restored vision; 22 vs. 15 days, respectively (mean, p = 0.024). Enucleation/evisceration occurred in patients with delayed fungal diagnosis of more than 14 days after initial presentation of symptoms. The most frequently isolated species was F. oxysporum (24.7%) followed by F. solani sensu stricto (18%) and F. petroliphilum (9%). The lowest MICs were obtained with amphotericin B followed by natamycin, voriconazole, and chlorhexidine. Conclusion: Although Fusarium keratitis remains a rare complication of CL wear, we found a significant increase of cases in the Netherlands. The course of infection may be severe and fungal diagnosis was often delayed. Antifungal treatment strategies varied widely and the treatment failure rate was high, requiring transplantation or even enucleation. Our study underscores the need for systematic surveillance of fungal keratitis and a consensus management protocol., (Copyright © 2020 Oliveira dos Santos, Kolwijck, van Rooij, Stoutenbeek, Visser, Cheng, Santana, Verweij and Eggink.)

Purpose: To evaluate the incidence of Acanthamoeba keratitis in the Netherlands between 2009 and 2015 and to analyse predicting factors for treatment outcome., Methods: Patient characteristics, diagnostic methods, diagnostic delay, therapy prior to and after diagnosis, and visual outcome were obtained from medical files of all patients diagnosed with Acanthamoeba keratitis in the Netherlands between 2009 and 2015. A logistic regression analysis on treatment failure, defined as a best corrected visual acuity of less than 20/40 Snellen decimals (i.e. >0.3 logMAR or an approximate loss of three lines of visual acuity) and/or the need for keratoplasty, was performed to determine predicting factors., Results: Two hundred and twenty-four eyes of 224 patients were included. Ninety-five percent of the patients were contact lens wearers, of whom 74% wore soft contact lenses. The number of cases increased from 16 in 2009 to 49 in 2015. This resulted in an estimated incidence of 1 in 21,000 for soft contact lens wearers in 2015. Eighty-seven eyes (39%) met the criteria for treatment failure. In a multivariable regression analysis, higher age at presentation, a higher severity stage and corticosteroid use before diagnosis were positively correlated with treatment failure. Early referral to a cornea specialist was associated with better clinical outcomes., Conclusions: Although Acanthamoeba keratitis is still a relatively uncommon disease, the incidence in soft contact lens wearers has increased to reach 1 in 21,000 in 2015. Treatment failure occurred in 39% of cases, with age, higher severity stage, corticosteroid use before diagnosis and indirect referral to a cornea specialist as important risks factors., Competing Interests: The authors have declared that no competing interests exist.

Fungal keratitis is a common but severe eye infection in tropical and subtropical areas of the world. In regions with a temperate climate, the frequency of infection is rising in patients with contact lenses and following trauma. Early and adequate therapy is important to prevent disease progression and loss of vision. The management of Fusarium keratitis is complex, and the optimal treatment is not well defined. We investigated the in vitro activity of chlorhexidine and seven antifungal agents against a well-characterized collection of Fusarium isolates recovered from patients with Fusarium keratitis. The fungus culture collection of the Center of Expertise in Mycology Radboudumc/CWZ was searched for Fusarium isolates that were cultured from cornea scrapings, ocular biopsy specimens, eye swabs, and contact lens fluid containers from patients with suspected keratitis. The Fusarium isolates that were cultured from patients with confirmed keratitis were all identified using conventional and molecular techniques. Antifungal susceptibility testing was performed according to the EUCAST broth microdilution reference method. The antifungal agents tested included amphotericin B, voriconazole, posaconazole, miconazole, natamycin, 5-fluorocytosine, and caspofungin. In addition, the activity of chlorhexidine was determined. The fungal culture collection contained 98 Fusarium isolates of confirmed fungal keratitis cases from 83 Dutch patients and 15 Tanzanian patients. The isolates were collected between 2007 and 2017. Fusarium oxysporum ( n  = 24, 24.5%) was the most frequently isolated species followed by Fusarium solani sensu stricto ( n  = 18, 18.4%) and Fusarium petroliphilum ( n  = 11, 11.2%). Amphotericin B showed the most favorable in vitro inhibition of Fusarium species followed by natamycin, voriconazole, and chlorhexidine, while 5-fluorocytosine, posaconazole, miconazole, and caspofungin showed no relevant inhibiting effect. However, chlorhexidine showed fungicidal activity against 90% of F. oxysporum strains and 100% of the F. solani strains. Our study supports the clinical efficacy of chlorhexidine and therefore warrants its further clinical evaluation for primary therapy of fungal keratitis, particularly in low and middle income countries where fungal keratitis is much more frequent and, currently, antifungal eye drops are often unavailable., (Copyright © 2019 Oliveira dos Santos et al.)

Infectious keratitis in contact lens wearers Infectious keratitis is a sight-threatening complication in contact lens wearers. The infection is most frequently caused by bacteria (Pseudomonas aeruginosa). However, fungi or Acanthamoeba are found in increasing frequency. Three cases illustrate a characteristic course: patient A (11-year-old male) was treated for three weeks before the characteristic aspect of Acanthamoeba keratitis was recognized and confirmed. Patient B (45-year-old female) developed a severe corneal ulcer within 4 days; microbiological diagnostics confirmed Pseudomonas aeruginosa keratitis. Examination of patient C (27-year-old female) showed an infiltrate with satellites, typical of fungal keratitis. It is important to check the use of contact lenses in patients with keratitis. Referral to the ophthalmologist is mandatory: immediate in cases with an infiltrate. A dentritiform epithelial lesion in a contact lens wearer is indicative of Acanthamoeba keratitis, whereas fungal keratitis shows satellites or feathering edges. Steroids may only be prescribed by an ophthalmologist after confirmation of the causative agent.

Purpose: To report an unusual case of bilateral Peters anomaly in Peters Plus syndrome., Methods: Systematic analysis and description of relevant clinical features, histopathological, and genetic findings., Results: A premature neonate, born after 34 weeks of gestation, presented with typical features of Peters Plus syndrome and bilateral corneal opacification with central clearing. Peters Plus syndrome was confirmed by the identification of a homozygous mutation in the B3GALTL gene. When a flat anterior chamber was observed and perforation was suspected both corneas necessitated corneal transplantation (left cornea transplanted at 4 weeks of age, right cornea at the age of 9 weeks). Histopathological analysis of the left cornea revealed a central defect with absence of all corneal layers except for the corneal epithelium. The right cornea revealed central absence of the corneal endothelium and Descemet membrane as well, but the central stroma consisted of a cellular meshwork rich in fibroblasts. There were no signs of iridocorneal or keratolenticular adhesions., Conclusions: We report the histopathology of serially obtained left and right cornea of a premature neonate with Peters Plus syndrome. As demonstrated in the left cornea, the child had a central defect of all corneal layers except for the corneal epithelium. Histopathological analysis of the right cornea obtained 5 weeks later revealed that the defect had induced fibrovascular tissue repair. The sequence of events we report in the corneas of our patient may help to better understand the pathogenesis of corneal (and anterior chamber) abnormalities in Peters Plus syndrome.

Purpose: Primary cataract is often the initial manifestation of the adult-onset type of myotonic dystrophy type 1 (DM1), the most common muscular dystrophy in adults. It is caused by a CTG repeat expansion within the DMPK gene, and anticipation may cause earlier onset and more severe symptoms in subsequent generations., Methods: We report a family with hereditary cataract, which was initially classified as primary hereditary cataract. After presentation of 2 children with motor development delay and behavioral changes, DM1 was diagnosed. Subsequently, various DM1 features were recognized in older family members., Conclusions: This report aims to increase awareness among ophthalmologists of the high prevalence of DM1 among young primary cataract patients. Ophthalmologists can play a significant role in early diagnosis, since cataract frequently is the first occasion that patients seek medical attention. Early recognition is crucial since it enables adequate cardiac follow-up and allows counseling of couples of childbearing age.

Purpose: To evaluate cost-effectiveness of penetrating keratoplasty (PK), femtosecond laser-assisted Descemet stripping endothelial keratoplasty (FS-DSEK), and Descemet stripping automated endothelial keratoplasty (DSAEK)., Design: Cost-effectiveness analysis based on data from a randomized multicenter clinical trial and a noncomparative prospective study., Methods: Data of 118 patients with corneal endothelial dysfunction were analyzed in the economic evaluation. Forty patients were included in the PK group, 36 in the FS-DSEK group, and 42 in the DSAEK group. The primary incremental cost-effectiveness ratio (ICER) was the incremental costs per clinically improved patient, defined as a patient with a combined effectiveness of both a clinically improved BSCVA (defined as an improvement of at least 2 lines) and a clinically acceptable refractive astigmatism (defined as less than or equal to 3.0 diopters). Analysis was based on a 1-year follow-up period after transplantation., Results: The percentage of treated patients who met the combined effectiveness measures was 52% for DSAEK, 44% for PK, and 43% for FS-DSEK. Mean total costs per patient were €6674 (US$7942), €12 443 (US$14 807), and €7072 (US$8416) in the PK group, FS-DSEK group, and DSAEK group, respectively. FS-DSEK was less effective and more costly compared to both DSAEK and PK. DSAEK was more costly but also more effective compared to PK, resulting in incremental costs of €4975 (US$5920) per additional clinically improved patient., Conclusions: The results of this study show that FS-DSEK was not cost-effective compared to PK and DSAEK. DSAEK, on the other hand, was more costly but also more effective compared to PK. Including societal costs, a longer follow-up period and preparation of the lamellar transplant buttons in a national cornea bank could improve the cost-effectiveness of DSAEK., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Purpose: To evaluate the cost effectiveness of deep anterior lamellar keratoplasty (DALK) versus penetrating keratoplasty (PK) in The Netherlands., Design: Cost-effectiveness analysis alongside a randomized, multicenter clinical trial., Methods: Fifty-three patients with corneal stromal pathologic features not affecting the endothelium were included with 28 patients in the DALK group and 25 in the PK group. Quality of life was measured before surgery and 3, 6, and 12 months after surgery. The main outcome measures were incremental cost-effectiveness ratios per clinically improved patient on the 25-item National Eye Institute Visual Functioning Questionnaire and per patient with endothelial cell loss of maximally 20% within the first year., Results: Mean total bootstrapped costs per patient were €7607 (US$10,498) in the DALK group and €6552 (US$9042) in the PK group. The incremental cost-effectiveness ratios were €9977 (US$13,768) per clinically improved patient on the 25-item National Eye Institute Visual Functioning Questionnaire and €6900 (US$9522) per patient with cell loss of maximally 20%. In patients without perforation of the Descemet membrane, the incremental cost-effectiveness ratio was €5250 (US$7245) per patient., Conclusions: This study shows that DALK is more costly and more effective as compared with PK. Results on the 25-item National Eye Institute Visual Functioning Questionnaire were in favor of DALK, and endothelial cell loss in DALK patients remained stable after 6 months, whereas cell loss in PK patients continued. Furthermore, DALK procedures performed without perforation of the Descemet membrane were more effective. However, because it is unknown what society is willing to pay for an additional improved patient, cost effectiveness of DALK within a limited follow-up period of 12 months is unclear. Cost effectiveness of DALK may improve over time because of lower graft failure., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Objective: To compare endothelial cell (EC) loss, visual and refractive outcomes, and complications after deep anterior lamellar keratoplasty (DALK) and penetrating keratoplasty (PK)., Design: Randomized, multicenter clinical trial., Participants: Fifty-six eyes of 56 patients with a corneal stromal pathology not affecting the endothelium were randomized to DALK or PK., Methods: The DALK procedure was performed according to Anwar's big-bubble technique. Patients underwent an ophthalmic examination preoperatively and 3, 6, and 12 months postoperatively., Main Outcome Measures: Endothelial cell loss, refractive and topographic astigmatism, spherical equivalent, uncorrected visual acuity, and best spectacle-corrected visual acuity (BSCVA) were measured, and complications were recorded., Results: Endothelial cell loss was significantly higher after PK compared with DALK procedures performed without perforation of Descemet's membrane (12 months: 27.7% ± 11.1% vs. 12.9% ± 17.6%). The BSCVA was significantly better in the PK group at 3 and 6 months after surgery but was not significantly different 12 months after surgery (0.39 ± 0.3 logarithm of the minimum angle of resolution [logMAR] in DALK and 0.31 ± 0.3 logMAR in PK). At 12 months postoperatively, refractive and topographic astigmatism in the DALK and PK groups were -3.37 ± 2.3 diopters (D) and -3.76 ± 2.1 D (P = 0.53), and 3.57 ± 2.3 D and 4.16 ± 2.0 D (P = 0.34), respectively. (Micro)perforation of the Descemet's membrane occurred in 32% (9/28) of the DALK eyes, and 18% (5/28) of the patients required conversion to PK. Endothelial cell loss was not significantly different between DALK and PK when cases with perforation of Descemet's membrane were included in the (intention-to-treat) analysis (12 months: 19.1 ± 21.6 vs. 27.7 ± 11.1 P = 0.112). Rejection episodes were reported in 1 patient in the DALK group (epithelial rejection) and 3 patients in the PK group (all endothelial rejections). No graft failure occurred., Conclusions: One year after DALK performed without perforation of Descemet's membrane, EC loss is significantly lower, whereas the BSCVA is comparable to that in the PK group. In addition, no endothelial rejection occurred in the DALK group. However, Descemet's membrane perforation remains a major complication in DALK and warrants improvements to standardize the big-bubble technique., (Copyright © 2011 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Background: To evaluate the efficacy and safety of femtosecond laser-assisted endothelial keratoplasty (FLEK) versus penetrating keratoplasty (PK) in patients with corneal endothelial disease., Methods: A randomized multicenter clinical trial of 80 eyes of 80 patients with corneal endothelial disease were randomized to FLEK or PK. Clinical outcomes (astigmatism and visual acuity) and incidence of postoperative complications were compared between the two groups., Results: At 12 months, the percentage of eyes with a refractive astigmatism less than or equal to 3 diopters was higher in the FLEK group in comparison with the PK group (86.2% vs. 51.3%, P=0.004). The mean postoperative best corrected visual acuity was 20/70+/-2 lines in the FLEK group and 20/44+/-2 lines in the PK group (P<0.001), but the gain in the best corrected visual acuity between the two groups was not significantly different. The endothelial cell loss in the FLEK and PK group was 65+/-12% and 23+/-15% (P<0.001). The most common postoperative complication in the FLEK group was graft dislocation (27.8%). Wound healing related problems occurred in six eyes (15%) in the PK group and in none of the FLEK eyes., Conclusions: FLEK effectively reduces postoperative astigmatism and results in an absence of wound healing related problems in patients with endothelial disease. However, visual acuity is lower as compared with conventional PK, and the high level of endothelial cell loss warrants a modification of the insertion technique of the endothelial graft.

Purpose: To investigate the long-term effect of oral acyclovir administered during the first 6 months after penetrating keratoplasty (PK) for herpetic eye disease (HED)., Methods: A 5-year follow-up was undertaken for a patient population from a placebo-controlled, randomized trial on acyclovir prophylaxis after keratoplasty. In this former study the effectiveness of oral acyclovir prophylaxis was significant during the first 2 years after keratoplasty. Prospective data such as graft survival, graft clarity, vascularization, infective events, and rejection episodes were obtained from the national keratoplasty follow-up registry. Additional clinical data were derived from the medical charts., Results: For 47 of the original 63 enrolled patients, the 5-year follow-up was completed. Comparing the acyclovir group with the placebo group, we found that with regard to the cumulative clinically evident recurrences, there was a statistically significant lower monthly event rate in the acyclovir group (P = 0.037). There were no statistically significant differences in visual acuity or in the use of oral aciclovir between the two treatment groups. The incidences of graft failure, vascularization, and medication or surgery for glaucoma were too low to analyze differences between the two groups., Conclusion: The results of our study suggest that oral acyclovir prescribed during the first 6 months after PK for HED protects against clinically evident HED recurrences during the first 5 years following PK.

Objective: To evaluate the preliminary visual results of femtosecond laser-assisted Descemet stripping endothelial keratoplasty (FS-DSEK)., Methods: We prospectively analyzed results of 20 consecutive patients with Fuchs endothelial dystrophy or aphakic/pseudophakic bullous keratopathy who underwent FS-DSEK. Best spectacle-corrected visual acuity (BSCVA), refraction, corneal topography, and endothelial cell density were measured preoperatively and 3 and 6 months after FS-DSEK. Corneal thickness was measured using an optical coherence tomography technique., Results: The average BSCVA of 11 eyes with normal visual potential significantly improved from 20/110 +/- 4 lines to 20/57 +/- 1 line at 6 months (P < .007). At 6 months, the mean (SD) hyperopic shift was 2.24 (2.3) diopters (D). Preoperative and 6 months postoperative refractive astigmatism were -0.75 (0.9) D and -1.58 (1.1) D (P = .01), but the topographic astigmatism did not change postoperatively (P = .95). Mean (SD) endothelial cell density at 6 months was 1368 (425) cells/mm(2). There was a persistent deswelling of the graft up to 3 months postoperatively. Complications included graft dislocations requiring repositioning (20%), pupillary block glaucoma (5%), epithelial ingrowth (5%), and primary graft failure (5%)., Conclusions: Femtosecond laser-assisted Descemet stripping endothelial keratoplasty was effective in treating endothelial failure with minimal induced refractive astigmatism, limited improvement of BSCVA, and induction of a hyperopic shift. Endothelial cell count and dislocation rate were significant, which may be related to the surgical technique.

Multiresistant Shigella flexneri isolates were cultured from the cornea and stool of a girl. Genetic analysis showed the isolates were identical. Shigella spp. are rare causes of ulcerative keratitis; there have only been 14 published cases since 1943. Although prognosis after local treatment is good, shigellosis is a systemic infection, possibly leading to dehydration.

A case of invasive Fusarium keratitis in a previously healthy male patient was treated successfully with cornea transplantation and systemic and topical voriconazole after treatment failure with topical amphotericin B and systemic itraconazole. Topical voriconazole was well tolerated, and, in conjunction with the oral administration, it resulted in a high level of the drug in the anterior chamber of the eye (which was 160% of the plasma drug level).

Objective: To determine the prophylactic effect of oral acyclovir on the recurrence rate of herpetic eye disease after penetrating keratoplasty., Design: A randomized, double-masked, placebo-controlled multicenter trial., Participants: Sixty-eight consecutive patients (68 eyes) with corneal opacities due to herpetic eye disease who underwent penetrating keratoplasty., Intervention: Oral acyclovir 400 mg twice daily or placebo tablets for 6 months., Main Outcome Measures: The recurrence rate of herpetic eye disease-related events and rejection episodes, proven by viral cell culture or polymerase chain reaction., Results: During the 2-year follow-up period, there were 3 culture-proven herpetic eye disease recurrences in the acyclovir group and 9 in the placebo group. Lifetime survival analysis of the probability of remaining free from recurrence revealed a significantly reduced risk of recurrent herpetic disease in the acyclovir-treated group., Conclusion: This study suggests that oral acyclovir effectively prevents herpes-related recurrences after penetrating keratoplasty in herpetic eye disease.

Objectives: To describe the refractive results of cataract surgery after photorefractive keratectomy (PRK) for patients with myopia, and to find a more accurate method to predict intraocular lens (IOL) power in these cases., Design: Nonrandomized, retrospective clinical study., Patients and Methods: Nine patients (15 eyes) who underwent cataract surgery after prior PRK to correct myopia were identified. The medical records of both the laser and cataract surgery centers were reviewed., Main Outcome Measures: Eight different keratometric values (K values; measured or calculated) were entered into 3 different IOL calculation formulas: SRK/T, Holladay 1, and Hoffer Q. The actual biometry and IOL parameters were used to predict postoperative refraction, which was compared with the actual refractive outcome. Also, the relative underestimation of the refractive change in corneal dioptric power by keratometry after PRK was calculated., Results: In 7 of 15 eyes, IOL exchange or piggybacking was performed because of hyperopia. Retrospectively, the most accurate K value for IOL calculation was found to be the pre-PRK K value corrected by the spectacle plane change in refraction. Use of the Hoffer Q formula would have avoided postoperative hyperopia in more cases than the other formulas. The mean underestimation of the change in corneal power after PRK varied from 42% to 74%, depending on the method of calculation., Conclusion: The predictability of IOL calculation for cataract surgery after PRK can be improved by using a corrected, refraction-derived K value instead of the measured, preoperative K value.

We present 3 cases of flap loss within 2 weeks of unilateral laser in situ keratomileusis. In all patients, spontaneous regeneration of the epithelial layer, covering the ablated stroma, was expected. In 2 patients, the best spectacle-corrected visual acuity recovered to 20/25 within 6 months and in 1 patient, a contact lens was fitted 6 months after the accident, restoring visual acuity to 20/25. The 6-month follow-up and the contact lens fitting technique are described.

Purpose: To report results of holmium laser thermal keratoplasty used to treat induced hyperopia and induced, as well as pre-existing astigmatism after photorefractive keratectomy., Methods: Sixteen eyes of 16 patients were included in this study. Contact holmium laser (Technomed Holmium 25) was used in 7 patients to correct hyperopia (8 spots at 8 or 9 mm) and in 9 patients to correct astigmatism (4 spots at 7, 8, or 9 mm). Follow-up evaluation was done after at least 6 months. The effectiveness, stability, and safety of the procedure were investigated., Results: Spherical correction was ineffective (1.00 D or less) when applied at the 9-mm diameter treatment zone. Spherical correction applied at the 8-mm diameter treatment zone was ineffective in 1 eye. Three eyes achieved 1.00 to 2.00 D change, but 2 of these eyes showed an induced astigmatic change as well. Correction of astigmatism at the 7-mm diameter treatment zone resulted in a 0 to 4.00 D cylinder component change. Treatment at the 8-mm diameter treatment zone showed a 0 to 1.50 D effect and at the 9-mm treatment zone, 0.25 to 1.50 D. All eyes that achieved significant improvement (1.00 D or more change in cylinder component) showed significant overcorrection in the first postoperative phase. There were no sight threatening complications., Conclusion: Holmium laser thermal keratoplasty can be useful for the treatment of overcorrection and induced as well as pre-existing astigmatism after photorefractive keratectomy. However, predictability is low and astigmatism can be induced with the attempted spherical correction.

Purpose: To evaluate efficacy, safety, and stability of photoastigmatic keratectomy (PARK) carried out with a Summit Apex Plus laser using an ablatable mask., Methods: Forty-one eyes of 41 patients with myopic astigmatism with follow-up of 12 months were evaluated. Treatment efficacy was compared in groups with high (>6.00 D) versus low (< or =6.00 D) preoperative spherical equivalent subjective manifest refraction, in groups with high (>2.00 D) versus low (< or =2.00 D) preoperative cylindrical component and in groups divided according to preoperative axis of cylinder., Results: At 12 months after surgery, mean spherical equivalent manifest refraction in all 41 eyes was -0.30 +/- 0.90 D. Mean cylinder component was 0.60 +/- 0.70 D. Mean reduction in astigmatic component was 67 +/- 47%. Uncorrected visual acuity of 0.5 or more was achieved in 79% of eyes; 71% of eyes achieved 0.8 or more. At 1 month after surgery, 49% of eyes had a loss of 2 or more lines of spectacle-corrected visual acuity. This loss was restored at 12 months. No statistically significant differences were found between the different subgroups., Conclusion: Photoastigmatic keratectomy with ablatable mask gives satisfactory results. No relation in efficacy was found when taking into account the amount of preoperative spherical component, the cylindrical component, or the cylinder axis direction.

Purpose: To evaluate the effectiveness, safety, and stability of contact Ho:YAG laser thermal keratoplasty for low to moderate hyperopia., Methods: Fifty-five hyperopic eyes of 39 patients were treated with a Technomed contact Ho:YAG laser; 23 eyes were treated a second time. Treatment parameters were 1 octagonal ring of 8 spots with a treatment diameter of 6 mm, 7 mm, or 8 mm. Efficacy of the Ho:YAG laser treatment was evaluated after 6 months, comparing 3 treatment zone diameters. Stability and efficacy after 12 months was evaluated comparing 7-mm and 8-mm treatment zone diameters., Results: Mean reduction of spherical equivalent refraction after 6 months was not statistically significantly different between the 6-mm or 7-mm diameter zones: 1.42 (+/- 1.30) D versus 2.22 (+/- 0.44) D. An 8-mm diameter treatment zone was significantly less effective, 1.12 (+/- 0.47) D. Longer follow-up did not show stability: mean reduction of spherical equivalent manifest refraction was 1.58 (+/- 0.45) D for the 7-mm diameter treatment zone and 0.82 (+/- 0.61) D for the 8-mm diameter treatment zone after approximately 12 months. Retreatment had a limited additive effect. No clinically significant loss of spectacle-corrected visual acuity was reported. No eyes lost more than 1 line of visual acuity., Conclusion: Contact Ho:YAG laser thermal keratoplasty corrected hyperopia up to 2.50 D, but predictability was poor and a regression of initial effect occurred. Instability of refraction persisted to 1 year after surgery.

A 59-year-old man developed bilateral keratitis several weeks after the initiation of mechanical ventilation because of respiratory failure and sepsis following abdominal surgery. Colonisation of the upper airways by P. aeruginosa had been established before. Invasion through corneal epithelial defects based on dehydration keratitis was the presumed route of infection. Despite aggressive treatment, including antibiotics, the infection was rapidly progressive in both eyes. The patient died of deterioration of his general condition. In order to prevent such eye infections in a patient on mechanical ventilation, there is a need of good eye care, prevention of corneal lesions and alertness, especially when the patient is colonised by virulent micro-organisms like P. aeruginosa.

Aims/background: To describe a bilateral, mid peripheral, ring-shaped corneal opacity, not resembling any known corneal degeneration, dystrophy, or other disorder, and occurring without ocular or systemic disease., Methods: Ophthalmic examination, haematological screening, and ultrasound biomicroscopy., Results: A 25 year old man showed grey-white, granular opacities in both corneas, with an 8 mm diameter ring configuration, and a V-shaped distribution in the anterior stroma. The surrounding corneal stroma was clear, and the tear film, the epithelium and its basement membrane, Descemet's membrane, and the endothelium were normal. Evidence of systemic disease was not found. Family members did not show corneal abnormalities., Conclusion: A bilateral corneal ring opacity may occur in healthy, asymptomatic, young people. These corneal rings may result from depositions of unknown origin, or possibly a rare corneal dystrophy.

Keratitis due to Nocardia farcinica occurred in a 49-year-old female after inappropriate cleaning of her semipermeable rigid contact lenses with basin-stored water during a holiday in France. N. farcinica was differentiated from Nocardia asteroides by its growth at 45 degrees C, acid production from rhamnose, its opacification of Middlebrook 7H10 agar, and its marked degree of resistance to all cephalosporins, aminoglycosides, tetracyclins, macrolides, and trimethoprim-sulfamethoxazole. To the best of our knowledge, this is the first reported case of human N. farcinica keratitis, confirming that this microorganism can be responsible for serious human disease.

Background: To report our experience with laser suture lysis (LSL) following trabeculectomy with mitomycin C, its timing, effectiveness and related complications., Methods: We retrospectively examined 38 consecutive eyes of 36 patients that underwent LSL following trabeculectomy with mitomycin C., Results: The mean preLSL intraocular pressure (IOP) was 27.0 mm Hg (SD 6.3, range 16-39 mm Hg) and the postLSL IOP (IOP 1 h after the last session of LSL) was 16.0 mm Hg (SD 7.2, range 3-31 mm Hg). Following the LSL in 7 eyes (7 of 38) hypotony (IOP<6 mm Hg, lasting more than 24 h) developed. Two groups were defined. In group I no hypotony was found after LSL and group II went through a period of hypotony. The time interval between surgery and LSL was significantly shorter in group II (mean 5.7, SD 7.5, range 1-19 days), compared to group I ( mean 14.7, SD 13.0, range 1-44 days) (p=0.041). The mean final IOP (IOP measured at the last visit) was 13.3 mm Hg (SD 3.4, range 6-20 mm Hg) and mean follow-up was 6.1 months (SD 3.9, range 2.0-15.2 months). No hypotony was found at final examination. PostLSL IOP and final IOP were significantly lower in group II (p=0.002 and p=0.024 respectively). IOP reduction by LSL was significantly greater in group II (p=0.046)., Conclusion: LSL is an effective and safe procedure to lower the IOP following trabeculectomy with mitomycin C. Early application of LSL results in lower final IOPs, but has a higher risk of hypotony.

Three patients, women aged 69, 25 and 30 years, with refractory keratitis were found to have a rare infection with Acanthamoeba. All wore soft contact lenses. The frequency of Acanthamoeba keratitis increased in recent years. At present, an efficacious antiprotozoal therapy is available, for instance in the form of polyhexamethylene biguanide and propamidine. In cases of refractory keratitis, the possibility of an Acanthamoeba infection should be taken into account.

Objective: Evaluation of the first excimer laser treatments of myopia., Design: Descriptive., Setting: Excimer Laser Centrum, Department of Ophthalmology, University of Nijmegen, Nijmegen, the Netherlands., Method: 312 patients underwent spherical excimer laser treatment to correct myopia of 1.2 up to 10 diopters between February 1992 and October 1993. 245 patients completed a follow-up of one year or more; 36 retreatments were carried out. Group I (treatment 1.2 to 6 D) numbered 174 patients, group II (6.1-10 D) 71 patients., Results: After a follow-up period of one year or just before retreatment 79% of group I and 48% of group II achieved a refractive correction within 1 D of the attempted correction. Visual acuity without correction was 0.5 or more in 94% of group I and in 76% of group II. Less than one percent (n = 1) of group I and 6% (n = 4) of group II lost more than one line of best corrected visual acuity. Retreatment could correct 50% of those eyes that did not achieve a refraction within 1 D of attempted correction. Loss of visual acuity was corrected by retreatment in 5 of 6 cases of group I and in 7 of 11 cases of group II., Conclusion: Based on a one-year follow-up, refractive surgery with the excimer laser appears to correct myopia between 1 and 10 D effectively. Predictability is diminishing on correcting higher amounts of refractive error. Thorough information of the patients regarding the results to be expected will prevent disappointment.

Due to economical reasons some ophthalmologists are using an irrigating solution made by the hospital pharmacy instead of the commercially available solutions. These irrigating solutions come in bottles which are identical to the ones used for other solutions. During the last three years bottles were accidentally mixed up five times. Consequently, bottles containing solutions such as chlorhexidine, cetrimide, chlorhexidine/centrimide and cialit solutions were used during cataract surgery. This resulted in immediate corneal edema which, in its turn resulted in a bullous keratopathy. Four patients underwent a penetrating keratoplasty. In one patient the cornea was covered with a conjunctival flap. Light microscopy of the corneas included epithelial edema, loss of keratocytes, and a disrupted and sometimes absent endothelial cell layer.

The authors report on a case of congenital bilateral protruding corneal opacities. Clinical and histological examination was consistent with a diagnosis of Peters' anomaly with a defect in the endothelium and Descemet's membrane but without abnormalities of iris and lens. Corneal grafting was performed on both eyes. During a follow-up period of one year the corneas have remained clear. However, surgical intervention for glaucoma has been necessary.

Three patients with the tilted disc syndrome from one family were examined. The presence of the trait in three consecutive generations suggests an autosomal dominant mode of inheritance, although in these patients with variable expression. The propositus showed bilateral inferonasal retinal ectasia, with atrophic subretinal scars. Linear-like lacquer cracks, radiating from the central scars, were also present running parallel to the margin of the optic nerve head. The linear streaks were very similar to those usually seen in traumatic tears of Bruch's membrane. The mechanical stretching of the ectatic area, and its abnormal location inferonasal to the optic disc might have been responsible for the unusual pattern of the lacquer cracks in our patient.