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Objective: To compare the efficacies of a single thermodynamic treatment system (LipiFlow®) and warm compresses used for 3 months in patients with a moderate severity of meibomian gland dysfunction (MGD). Methods: This prospective, randomized, controlled clinical study enrolled 28 patients (22 females, 6 males; mean age, 53.9 ± 14.8 years) diagnosed as having moderate MGD by plugging at the meibomian gland orifices between one-third and two-thirds of lid margins and at least one of the following: a Standard Patient Evaluation of Eye Dryness (SPEED) questionnaire score of 6-12; a lipid layer thickness (LLT) score of 40-70 Interferometric Color Units; upper eyelid meiboscore of 1-2; and 3-6 expressible meibomian glands (EMGs) in the lower eyelid. Both eyes of each patient were randomized into study and control eyes. Study eyes were treated with a single, 12-minute LipiFlow® system, while control eyes received 5-minute warm compresses twice daily for 3 months. The dry eye symptoms, the number of EMGs, and LLTs were evaluated. Results: There were no significant differences in the dry eye symptoms, number of EMGs, and LLTs for both groups at baseline and at each follow-up. However, the total SPEED scores for the LipiFlow® group reduced significantly from baseline at each follow-up until 6 months. As to the warm compress group, the total SPEED scores reduced significantly from baseline at each follow-up until 3 months. Conclusion: The single LipiFlow® treatment and twice-daily warm compresses relieved the dry eye symptoms of patients with a moderate severity of MGD compared with their baseline symptoms, despite no statistical differences in the dry eye symptoms, number of EMGs, and LLTs of both treatments. [ABSTRACT FROM AUTHOR]

Objective: To determine two-year outcome of intrastromal corneal ring segment (ICRS) implantation in keratoconus in Thai patients Methods: A retrospective review of medical records of the patients underwent Ferrara-type ICRS implantation (single and two segments) at Siriraj Hospital between November 2013 and December 2017 was conducted. Clinical outcomes were assessed at 1 month, 6 months, 1 year, and 2 years postoperatively. Results: Of 9 eyes in 8 patients, the mean age of the patients was 24.6 ± 7.5 years. The mean follow-up time was 32.2 ± 9.4 months. Overall, the median visual acuity was significantly improved postoperatively (p value = 0.007). At 2 years, the uncorrected visual acuity (UCVA) improved from 1.00 logMAR to 0.56 logMAR, and the corrected distance visual acuity (CDVA) improved from 0.76 logMAR to 0.10 logMAR. Correspondingly, the median spherical equivalent refraction was significantly improved postoperatively from -7.38 D to -3.13 D (p < 0.001). Moreover, the median anterior corneal topographic data significantly changed between visits (p < 0.02). The Kmax decreased from 52.65 D to 46.65 D and the Kmean decreased from 48.10 D to 45.40 D at 2 years. Postoperative adverse effects were glare and halos (3 eyes), visually insignificant small white corneal deposits around the segments (2 eyes), extrusion of a ring segment needed removal with reversible to baseline vision (1 eye). Conclusion: This initial report in Thai patients showed that the ICRS implantation in keratoconus could improve the visual, refractive, and topographic parameters with stability at 2 years. However, appropriate case selection and surgical technique should be considered. [ABSTRACT FROM AUTHOR]

Objective: The primary objective was to find an agreement of intraocular pressure (IOP) assessed by Goldmann applanation tonometry (GAT) and Corvis in healthy, ocular hypertension (OHT) and primary open-angle glaucoma (POAG). The secondary objective was to find a reliability of intra-examiner and inter-examiner IOP measurement by GAT and Corvis. Methods: Fifty three eyes from 53 participants were included and were divided into healthy (N=20), OHT (N=13) and POAG group (N=20). Only right eyes were selected for further statistical analysis except one patient with only left eye eligible. The eyes with corneal pathologies, greater than 2.5 diopters astigmatism, or recent ocular surgery were excluded. Randomized examining sequence between GAT and Corvis was applied. To minimize an after measurement IOP fluctuation, five minutes and two minutes gap between measurements were strictly applied for Corvis and GAT respectively. The first ten patients had 3 measurements per measurer and two measurers were assigned per machine to evaluate intra-examiner and inter-examiner reliability. Intraclass correlation coefficient was used to analyze the reliability of the IOP measuring machine. Bland & Altman plot was used to analyze an agreement between the machines. Results: High ICCs were found in both measurers using GAT (ICC of measurer 1 = 0.954, measurer 2 = 0.977) and Corvis (ICC of measurer 1 = 0.920, measurer 2 = 0.927) which indicated excellent intra-examiner reliability. High ICCs were found when comparing IOP between 2 measurers who used the same machine (GAT ICC = 0.928, Corvis ICC = 0.915) which indicated excellent inter-examiner reliability. GAT tends to yield higher IOP reading. The mean IOP were 13.93±3.849 by GAT and 12.15±4.030 by Corvis. The mean IOP differences were 1.8, 1.7, 1.4 and 2.2 mmHg in total, healthy, OHT and POAG group respectively. POAG had highest mean difference and widest standard deviation which might result from poor agreement between 2 machines. According to Bland & Altman plot the values were scattered and no trend was found indicating higher or lower average IOP would result in higher or lower difference between the two machines. From the clinical point of view, 71.7% and 47.2% fall into IOP difference range of ±3 and ±2 mmHg respectively. Conclusion: Corvis-IOP is a good parameter with excellent intra-examiner and inter-examiner reliability. In clinical practice, the usefulness of Corvis-IOP is limited especially in POAG patients according to the poor agreement with gold standard GAT-IOP. [ABSTRACT FROM AUTHOR]

Background: Delayed diagnosis can lead to the development of endophthalmitis and blindness, which is difficult to manage because of the lack of an effective antimicrobial agent., Objective: Comparing the nested polymerase chain reaction (PCR) technique with the standard diagnostic culture method for Pythium insidiosum., Material and Method: Eighty-three patients with suspected fungal keratitis were enrolled in this observational, crosssectional study from the Faculty of Medicine Siriraj Hospital between February 2011 and February 2014. Patient symptoms, associated diseases, duration of ulcers, precipitating causes, best-corrected visual acuity, intraocular pressure, and other clinical findings were recorded. Corneal scrapings were taken for Gram staining, bacterial and fungal cultures, staining with potassium hydroxide preparation, and DNA extraction for nested PCR. The sensitivity, specificity, accuracy, and agreement of the nested PCR analysis and culture diagnosis of P. insidiosum were compared., Results: Five patients had a positive result for nested PCR amplification of P. insidiosum, while only one of these was also positive for culture growth of Pythium. Nested PCR sensitivity was 50% (95% confidence interval [95% CI] 1.3-98.7), specificity 94.7% (95% CI 86.9-98.5), and accuracy 93.5% (95% CI 85.7-97.2) with a fair agreement (kappa 0.258, p = 0.011)., Conclusion: Therefore, nested PCR may be an appropriate test for P. insidiosum in diagnosing Pythium keratitis with high accuracy, despite small amounts of corneal specimen.

Objective: To show the association between keratoconus and macular dystrophy., Material and Method: All patients with macular dystrophy and associated clinical findings leading to a diagnosis of keratoconus by corneal topography were retrospectively reviewed during a 10-year period. Uncorrected and best-corrected visual acuity, automated refraction, manifest refraction, corneal thickness, and corneal curvature by corneal topography were evaluated, Results: Three patients with macular dystrophy exhibiting decreased vision, multifocal white dense deposits, and haze surrounding the deposits in the corneal stroma were evaluated. All had a steep corneal curvature of >47 diopters and a thin cornea consistent with keratoconus. Penetrating keratoplasty was performed in one patient with severely decreased vision. Macular dystrophy was diagnosed based on an Alcian blue-stained pathological specimen., Conclusion: Keratoconus may develop as a result of changes associated with macular dystrophy. Therefore, patients with severely decreased vision should be evaluated for keratoconus to ensure proper management.

Diagnosis of Pythium keratitis is problematic due to the difficulty in obtaining a culture report resulting in unnecessarily prolonged usage of antimicrobial medication due to misdiagnosis. This study evaluated and compared nested PCR technique with culture and immunoperoxidase staining assays of Pythium insidiosum in paraffin-embedded corneal tissues from patients with suspected fungal keratitis. Six of 51 pathological reports compatible with fungal infection and 6 of 48 culture-proven fungal keratitis were identified as Pythium. Twenty-seven specimens were PCR-positive for Pythium insidiosum. In comparison with fungal culture for P. insidiosum, PCR had 83% sensitivity and 77% specificity with fair agreement (Kappa score of 0.227, p = 0.001). The mean age of PCR-positive is younger than PCR-negative group and there is a female preponderance in Pythium-infected group (p = 0.002 and p = 0.004, respectively). Nineteen specimens had positive results using immunoperoxidase staining assay with fair agreement to culture method (Kappa 0.340, p < 0.001), and 83% sensitivity, 85% specificity and 85% accuracy (95% CI: 76.7-90.7). PCR-based technique compared with culture and/or immunoperoxidase staining assay had 91.7% sensitivity, 81.8% specificity and 83% accuracy (95% CI: 74.5-89.1) with moderate agreement (Kappa 0.477, p < 0.001). Thus nested PCR detection of P. insidiosum should be employed in preliminary diagnosis of Pythium keratitis in order to initiate proper management.

Objective: To compare the efficacy of 0.1% tacrolimus (FK-506) ophthalmic ointment with 2% cyclosporine eye drops in the treatment of vernal keratoconjunctivitis (VKC)., Design: Prospective double-masked randomized comparative trial., Participants: Twenty-four VKC patients were enrolled into the study. Their mean age was 9.61 +/- 2.55 years. Twelve patients were allocated into the FK-506 group and the other twelve into the cyclosporine group. Their baseline characteristics were similar between groups., Methods: After a 2 week run-in period, patients were randomized into 2 groups in a double-masked, parallel fashion. Group A received 0.1% FK-506 eye ointment twice daily with placebo eye drops four times daily for 8 weeks. Group B received 2% cyclosporine eye drops with placebo ointment for the same duration. All patients received an open-treatment with 0.1% FK-506 eye ointment for another 4 weeks. Subjective ocular symptoms and side effects were recorded by patients once daily, during the entire period. Objective ocular signs were evaluated and scored at each follow up visit., Main Outcome Measure: Improvement of total subjective symptom scores per day (TSSS) within group and between groups at various time points., Results: For within group comparison, there was a significant decrease in TSSS, compared to their baselines, at weeks 4 and 8, in both treatment groups. However, no statistical difference in TSSS was noted between groups at any time point. Total ocular sign scores (TOSS) in the FK-506 group decreased significantly at weeks 4 and 8 compared to baseline. Although there was a decrease of TOSS in the cyclosporine group, the difference did not reach statistical significance. Side effect scores reduced significantly in both groups at week 4 compared to their respective baselines (p = 0.034 in the FK506 group and p = 0.003 in the cyclosporine group). There was no significant difference in the comparison between groups on TOSS and side effect scores at any time point of the study. During the open FK-506 period, patients in cyclosporine group showed further reduction of both TSSS and TOSS. However, these changes were not statistically significant (p > 0.05)., Conclusion: 0.1% FK-506 eye ointment and 2% cyclosporine were both effective in treatment of VKC. 0.1% FK-506 could become another viable therapeutic option for VKC.

Objective: To evaluate the risk factors that may contribute to microbial keratitis in contact lens wearers., Material and Method: This prospective case-control study included 52 patients with contact lens related keratitis treated between 1 December 2006 and 15 October 2007 at the Faculty of Medicine, Siriraj Hospital. Controls were sixty-three contact lens users attending with disorders unrelated to contact lens wear All subjects with informed consent were interviewed about demographic data, types of contact lens and contact lens solutions, contact lens use past the recommended replacement date, overnight wear, and lens hygiene. Odds ratio (OR, estimates of relative risks) and 95% confidence interval (CI) were calculated through multivariable logistic regression analysis., Results: The use of contact lens past the replacement date caused the highest risk of developing microbial keratitis (OR = 9.1; CI 1.8-45.4, p = 0.005). Overnight wear of lenses (OR = 2.9, CI 1.3-6.2, p = 0.012) and poor lens hygiene (OR = 2.3, CI 1.0-5.1, p = 0.007) significantly increased the risk of microbial keratitis, respectively. None of the other risk factors showed a significant association., Conclusion: The significant risk factors for contact lens related microbial keratitis in the present study were the use of contact lens past the replacement date, overnight wear, and poor lens hygiene. Thus, the appropriate advice of contact lens care and usage may reduce the risk of microbial keratitis in contact lens wearers.

Objective: To evaluate refractive outcomes of myopic femtosecond LASIK at Siriraj Hospital, Thailand., Material and Method: A retrospective study of patients who underwent femtosecond LASIK at SiLASIK center Siriraj hospital, Mahidol University, Thailand,from April 2009 to April 2010 was conducted. All patients had completely normal preoperative eye examination. All LASIK procedures were performed using Intralase femtosecond laser (Abbott Medical Optics Inc (AMO)) and VISX star S4 excimer laser (AMO). Postoperative follow-up included visual acuity (ETDRS chart) and manifest refraction at 1 day, 1 week, 1 month and 3 months. The flap thickness was evaluated at 3 months using Visante optical coherence tomography (OCT Carl Zeiss Meditec)., Results: One hundred and twenty eight eyes of 64 patients were included in the study. Mean preoperative manifest refraction spherical equivalent (MRSE) was -5.47 +/- 2.28 diopters (range, -1.88 to -12.63 diopters). At 3 months post-operation, the MRSE was -0.26 +/- 0.39 diopters (range, + 0.25 to -2.00 diopters) and 95.31% were within + 1.00 diopter of intended correction. There was 98% of eyes achieved uncorrected distance visual acuity (UDVA) 20/40 or better and 73% achieved UD VA 20/20 or better There was 31% of eyes gained one line and 15% lost 1 line of corrected distance visual acuity (CDVA). The mean error of flap thickness (difference between actual and intended central flap thickness) was + 0.23 +/- 1.77 microm for 120 microm flap setting and + 0.22 +/- 0.97 microm for 110 microm flap setting. The flap morphology was planar configuration., Conclusion: Myopic femtosecond LASIK at Siriraj Hospital provided satisfactory refractive outcomes and high accuracy of the flap thickness.

Background: Rheumatoid arthritis has manifestations in various organs including ophthalmic involvement. The present study evaluates prevalence of dry eye and secondary Sjogren's syndrome using salivary scintigraphy which has not been used in previous reports., Objective: To evaluate the prevalence of secondary Sjogren's syndrome in patients with rheumatoid arthritis, including clinical characteristics and dry eye, compared with non-Sjogren's syndrome., Design: Descriptive cross sectional study, Material and Method: Sixty-one patients with rheumatoid arthritis were recruited at Siriraj Hospital during March 2009-September 2010 and filled in the questionnaires about dry eye for Ocular Surface Disease Index (OSDI) with a history taking of associated diseases, medications, duration of symptoms of dry eyes and dry mouth. The Schirmer I test without anesthesia, tear break-up time, rose bengal staining score, severity of keratitis and salivary scintigraphy were measured and analyzed., Results: Prevalence of secondary Sjogren's syndrome and dry eye were 22.2% (95% CI 15.4 to 30.9) and 46.7% (95% CI 38.0 to 55.6), respectively. Dry eye interpreted from OSDI, Schirmer 1 test, tear break-up time and rose bengal staining was 16.4%, 46.7%, 82% and 3.3% respectively. Fifty-two percent of patients had a history of dry eye and dry mouth with mean duration 27.4 and 29.8 months, respectively. Superficial punctate keratitis and abnormal salivary scintigraphy were found in 58.2% and 77.8%. Duration of rheumatoid arthritis, erythrocyte sedimentation rate were not correlated with secondary Sjogren's syndrome. Dry eye from OSDI with secondary Sjogren's syndrome (33.3%) compared with non-Sjogren's syndrome (9.5%) was significant difference (p = 0.008). Adjusted odds ratio for secondary Sjogren's syndrome in OSDIL score > 25 was 13.8 (95% CI 2.6 to 73.8, p = 0.002) compared to OSDI score < 25., Conclusion: Awareness and detection of dry eye syndrome and secondary Sjogren's syndrome in rheumatoid arthritis was crucial for evaluation of their severity and proper management.

Three clinical isolates of Acanthamoeba (A. castellanii, A. polyphaga, and A. mauritaniensis) were used to evaluate the cysticidal activity of four different contact lens multi-purpose solutions (Complete Protec, ReNu MultiPlus, Solocare Aqua, and Opti-free Aldox). Enumeration of amoebic was carried out with the control and test samples at 0, 2, 4, 6, 8, 10, and 24 hours after being added to the solutions using the most probable number (MPN) technique. A contact lens solution which achieved a 3-log reduction of Acanthamoeba during the manufacturer's minimum recommended disinfection time (MMRDT) was considered an effective solution. The studied contact lens solutions demonstrated decreasing number of amoebic with increasing exposure times, but were not effective against Acanthamoeba cysts during the MMRDT. Solocare Aqua gave the greatest reduction in A. castellanii (0.70-log reduction) and A. mauritaniensis (0.33-log reduction) by 4 hours. Only Solocare Aqua caused a 3-log reduction in A. castellanii (3.02-log reduction) by 24 hours. Opti-free Aldox showed the greatest cysticidal activity against A. polyphaga (0.32-log reduction) by 6 hours, and gave the greatest reduction in A. mauritaniensis by 8, 10, and 24 hours.

Objective: To study the incidence of dry eye in Sjögren-like syndrome, graft-versus-host disease (GVHD) in hematological patients undergoing bone marrow transplantation (BMT)., Material and Method: Prospective, cross-sectional study in twenty-six patients that were planned for BMT (group I). Twenty-nine patients undergoing BMT before study were classified as group II no GVHD (9), and group III with GVHD (20). Thirty-two normal subjects were controls. All subjects were examined by slit lamp biomicroscopy and had their tear samples analyzed about tear osmolarity. They were also evaluated for aqueous tear production by phenol red thread test, Schirmer test without anesthesia, tear film stability by tear break-up time (TBUT), and rose bengal staining 2 weeks before BMT (for group I) as well as 6 weeks, 3 months, and 6 months after BMT. The patients with GVHD were followed up 1 month later. Main outcome measures were amount of tear production, tear film stability, and dry eye symptoms., Results: Average aqueous tear production in group III was less than control and group II (p < 0.001). Mean TBUT in group III was faster than control (p < 0.001) and group I before BMT (p = 0.001). Mean score of rose bengal staining in group III was more than control and group I before BMT (p < 0.001). Keratoconjunctivitis sicca and red eye developed in 27.5%, and 20% of group III, with incidence of dry eye by Schirmer test without anesthesia (67.5%). This compares with group II having incidence of dry eye of 16.7%. However, 42.3% of group I before BMT had dry eye compared with 9.4% in the controls (p < 0.001)., Conclusion: Trend of dry eye in patients with BMT and GVHD were higher than no-GVHD group. Doctors should be aware of ocular symptoms and signs of dry eye in patients with BMT and follow-up for proper management.

Objective: To evaluate the change in intraocular pressure (IOP) measurement by Goldmann applanation tonometer after Laser in Situ Keratomileusis (LASIK) for myopia and myopic astigmatism, and to assess the correlation between the changes of lOP reading and the reduction of central corneal thickness (CCT) after LASIK in Thai patients., Study Design: Prospective correlational study., Material and Method: LASIK was performed on 65 eyes of 33 patients for correction of myopia and myopic astigmatism. IOP was measured by Goldmann applanation tonometer before and 3 months after LASIK. The correlation between the change in IOP reading and the change in central corneal thickness were evaluated., Results: IOP reading was significantly reduced by mean of 2.9 +/- 2.5 mmHg (p = 0.0001). The authors used Pearson analysis to study the correlation between the change in IOP and the reduction of CCT. In subgroup analysis the patients were divided by degree of myopia: group 1, myopia less than -3 diopters (D) (n = 14); group 2, myopia -3 to -6 D (n = 31); group 3, myopia greater than -6 D (n = 20)). The result showed more correlation in higher myopia group (Pearson; r = 0.158 in group 3, r = -0.098 in group 2 and r = -0.102 in group 1)., Conclusion: Goldmann applanation tonometry underestimates the IOP in thin cornea. Variability in CCT is a potent confounder of this tonometry technique. Therefore, it has important implications for considering CCT measurement incorporated with Goldmann applanation tonometry for glaucoma diagnosis especially in myopic patients who undergo LASIK surgery.

Purpose: To compare the efficacy and safety of topical lomefloxacin 0.3 per cent with topical ciprofloxacin 0.3 per cent for treating mildly severe suspected bacterial corneal ulcers., Method: This prospective, randomized, double-masked controlled clinical trial was conducted on 41 patients (41 eyes) with suspected bacterial corneal ulcers who were randomized into 2 groups: 23 patients were in the lomefloxacin group and 18 patients in the ciprofloxacin group. All of these corneal ulcers were scraped for gram's stain, KOH preparation and microbiologic cultures before starting treatment. The clinical success rate, the time to cure, the rates of treatment failures, ocular signs and symptoms and the adverse effects of the study medication were evaluated., Results: Topical lomefloxacin is equivalent clinically and statistically to topical ciprofloxacin. No statistically significant treatment differences were found between lomefloxacin (100%) and ciprofloxacin (100%) in terms of success rate. Similarly, no differences were noted in the time to cure (p > 0.05), the treatment failure, or the resolution of the clinical signs and symptoms (p > 0.05). The adverse effects of lomefloxacin were superficial punctate keratitis (26.1%) and irritation (8.7%), whereas those of ciprofloxacin were superficial punctate keratitis (22.2%), white precipitate (11.1%) and irritation (11.1%). However, no statistically significant differences of these adverse effects were found between the two groups (p > 0.05)., Conclusion: Lomefloxacin ophthalmic solution (0.3%) is equivalent clinically and statistically to ciprofloxacin ophthalmic solution (0.3%) for the treatment of mildly severe presumed bacterial corneal ulcers without statistically significant differences in the adverse effects and discomfort.

A prospective, randomized cross-over study was conducted in patients with vernal keratoconjunctivitis, successfully treated with cyclosporine, to evaluate the efficacy of cyclosporine 0.5 per cent compared with preservative-free ketorolac tromethamine 0.5 per cent. Patients received topical cyclosporine in both eyes along with an assessment of the severity of their conjunctivitis. In cyclosporine-treated patients, medication was discontinued 1 week before evaluation, then the medication was started for I month, and washed out 1 week before the other drug was started. Symptoms of itching, foreign body sensation, tearing, photophobia, discharge, burning, conjunctival injection, chemosis, giant papilla, keratopathy and intraocular pressure were evaluated weekly. There was a statistically significant decrease in all symptoms of cyclosporine-treated eyes at day 7, 14 and 30 and all signs at day 21 and 30. In ketorolac-treated eyes, there was a significant difference in itching, foreign body sensation, photophobia, tearing, mucous discharge, all symptoms, chemosis, giant papillae and conjunctival injection at day 7, and overall symptoms at day 14. Compared to cyclosporine-treated eyes at day 7, kotorolac-treated eyes had significantly fewer symptoms. Topical cyclosporine 0.5 per cent reduces symptoms and signs slower than preservative-free ketorolac tromethamine 0.5 per cent.

Aims: To compare the efficacy and ocular adverse effects of topical prednisolone acetate, ketorolac tromethamine, and fluorometholone acetate in reducing inflammation after phacoemulsification., Method: One hundred and twenty eyes were enrolled in a prospective, investigator-masked, randomized controlled trial. Each drug was prescribed 4 times a day for 28 days. The following data were recorded weekly: visual acuity, intraocular pressure, slit lamp biomicroscopy, grading of cells and flare in the anterior chamber, and ocular symptoms., Results: The number of eyes with a minimal amount of cells in the anterior chamber in the ketorolac group was less than the prednisolone group on day 7 (11:20, p = 0.008) and day 14 (23:31, p = 0.015), and than fluorometholone group on day 7 (11:21, p = 0.011). Intraocular pressure in the prednisolone group was higher than the ketorolac group on day 21 (14.6:12.2 mmHg, p = 0.016). One eye in the prednisolone group had intraocular pressure of 32 mmHg. Burning sensation was reported frequently in the ketorolac group., Conclusion: All 3 drugs were effective in reducing post-operative inflammation. The efficacy of prednisolone acetate and fluorometholone acetate was comparable. Ketorolac tromethamine showed less efficacy than corticosteroids, however, it did not induce ocular hypertension.