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The purpose of this study was to report the 2-year outcomes of a double-blinded randomized controlled trial comparing Descemet membrane endothelial keratoplasty (DMEK) and microthin Descemet stripping automated endothelial keratoplasty (MT-DSAEK).Fifty-six eyes of 56 patients were randomized to DMEK or microthin DSAEK (MT-DSAEK). The main outcome measure was best spectacle-corrected visual acuity (BSCVA) at 24 months. Other secondary outcomes included complications, endothelial cell density, and vision-related quality-of-life (vQoL) scores.There was no statistically significant difference in BSCVA between the DMEK and MT-DSAEK groups at the 2-year time point (mean ± SD; 0.04 ± 0.14 vs. 0.12± 0.19, P = 0.061) in contrast to the 1-year results (mean ± SD; 0.04 ± 0.13 vs. 0.11 ± 0.09, P = 0.002) previously reported. Endothelial cell density did not show a statistically significant difference at 24 months between the DMEK and MT-DSAEK groups (1522 ± 293 cell/mm2 vs. 1432 ± 327 cells/mm2, P = 0.27). There were 2 additional graft rejection episodes in the MT-DSAEK group between the 1- and 2-year follow-up periods, but this did not result in graft failure. The mean vQoL scores between DMEK and MT-DSAEK indicated similar patient satisfaction between the groups (97.1 ± 4.0 vs. 92.6 ± 10.2, P = 0.13).In summary, the trial showed no significant difference in BSCVA at 24 months between the DMEK and MT-DSAEK groups. Both techniques continued to demonstrate comparable outcomes for complication rates, endothelial cell loss, and patient-reported vQoL scores.ISRCTN10578843.

Congenital aniridia is caused by a mutation in the PAX6 gene [1] and is characterized by partial or complete absence of iris tissue. Apart from the hypoplasia of iris tissue, other ocular features such as foveal hypoplasia, nystagmus, aniridia-related keratopathy, Peters anomaly, Axenfeld-Rieger anomaly and glaucoma are seen in these eyes [1,2]. Cases have been reported with persistent pupillary membranes [3] and iris strands [4].

Purpose To compare visual outcomes, complications, and vision-related quality of life (QoL) after microthin Descemet stripping automated endothelial keratoplasty (MT-DSAEK) versus Descemet membrane endothelial keratoplasty (DMEK) for the management of corneal endothelial dysfunction in Fuchs dystrophy. Methods This is a prospective, double-blinded randomized controlled clinical trial. Patients with visually significant endothelial decompensation from Fuchs dystrophy were prospectively randomized to receive MT-DSAEK or DMEK surgery. The primary outcome was best spectacle-corrected visual acuity (BSCVA) at 12 months. Secondary outcomes included refraction, keratometry, endothelial cell count, complications, and vision-related QoL at 6 and 12 months postoperatively. Results A total of 56 eyes of 56 patients were enrolled, 28 in each group. Postoperatively, LogMAR mean BSCVA in the MT-DSAEK group was 0.17 ± 0.08 and 0.11 ± 0.09 at 6 and 12 months compared with 0.09 ± 0.13 and 0.04 ± 0.13 after DMEK (P = 0.03, P = 0.002 respectively) with the DMEK cohort achieving 3.5 logarithm of the minimum angle of resolution letters better BSCVA at 1 year compared with MT-DSAEK. Complication rates were similar with 3.5% rebubbling rate in both groups, 1 primary graft failure in DMEK and a single endothelial rejection in the MT-DSAEK arm. Vision-related QoL was comparable at 6 and 12 months postoperatively, and no eyes demonstrated loss of vision from preoperative BSCVA. Conclusions DMEK surgery resulted in significantly better BSCVA at 1, 3, 6, and 12 months postoperatively compared with MT-DSAEK. Patient satisfaction was similar with no differences reported in vision-related QoL scores, as was the complications profile between groups. Thus, our results favor DMEK as the better choice procedure for eyes with Fuchs-related corneal decompensation without ocular comorbidities.

The human corneal endothelium (CE) is a post-mitotic monolayer of endothelial cells, thought to be incapable of in vivo regeneration. Dysfunction of the CE is a commonly cited indication for corneal transplantation, with corneal blindness being the fifth most common cause of blindness globally. In 2012 alone 184,576 corneal transplants were performed in 116 countries (Gain et al., 2016). Presently, outcomes following human corneal transplantation have been reported to have over 97% success rate in restoring the recipient's vision (Patel et al., 2019). However, the continuing demand for cadaveric human corneas has driven research into alternative sources of CE and with the advent of protocols to produce cultured hCECs there is now the potential for cell therapy to regenerate the damaged CE. This review aims to examine the merits and limitations of different types of human and animal models used so far to test the concept of CE cell therapy.

Cornea diseases are a leading cause of blindness and the disease burden is exacerbated by the increasing shortage around the world for cadaveric donor corneas. Despite the advances in the field of regenerative medicine, successful transplantation of laboratory made artificial corneas has not been fully realised in clinical practice. The causes of failure of such artificial corneal implants are multifactorial and include latent infections from viruses and other micorbes, enzyme over-expression, implant degradation, extrusion or delayed epithelial regeneration. Therefore, there is an urgent unmet need for developing customized corneal implants to suit the host environment, counter the effects of inflammation or infection and that are able to track early signs of implant failurein situ. In the present work, we describe a nano toolbox comprising tools for drug release and in addition capable of being infection responsive, promoting regeneration including non-invasive monitoring ofin situcorneal environment. These nano constructs can be incorporated within pro-regenerative biosynthetic implants, transforming them into theranostic devices able to respond to biological changes following implantation.

This is a case of a 17-year-old patient with aniridia-related keratopathy and persistent epithelial defect (PED) treated successfully using maternal finger-prick blood (FPB). Maternal allogenic FPB treatment was initiated to the patient who was non-compliant with the use of autologous FPB. The PED was successfully managed with maternal FPB treatment with rapid and complete closure of the epithelial defect. Additionally, there was immediate and sustained symptomatic improvement to pain and recovery of vision in the only seeing eye. There was no immunological reaction to allogenic blood. Maternal finger-prick allogenic blood could serve as a potential alternative to serum eye drops or autologous FPB in the management of refractory PED, particularly in reference to the paediatric or the vulnerable age group. Further studies are required to confirm the role of allogenic blood in the treatment of PED.

Purpose: To test the feasibility of a cell-therapy approach to treat corneal endothelial (CE) disorders using an in vitro model of human corneal decompensation. Materials and Methods: A CE decompensation model was established by removal of the DM/Endothelium complex from human cadaveric corneas in an air-interface organ culture system (Group 2) and compared to normal corneas (Group 1). The posterior stroma of decompensated corneas was seeded with immortalized human corneal endothelial cells (HCEC-12) in Group 3 and passage 0 primary human corneal endothelial cells (hCECs) in Group 4 corneas. Functional effects on stromal thickness were undertaken with histological analysis 3-10 days post-cell therapy treatment. Results: Removal of the DM/Endothelium complex in Group 2 corneas resulted in a stromal thickness of 903 ± 86 μm at 12 hours in comparison to 557 ± 72 μm in Group 1 corneas. The stromal thickness reduced from 1218 ± 153 μm to 458 ± 90 μm (63 ± 6 %, p=0.001) post cell transplantation in Group 3) and from 1100 ± 86 μm to 489 ± 94 μm (55 ± 7 %, p=0.00004 in Group 4 respectively. Post-transplantation histology demonstrated the formation of a monolayer of corneal endothelium attached to the posterior stromal surface. Conclusion: Direct transplantation of cultured hCECs and immortalized HCEC-12 to bare posterior corneal stroma resulted in the formation of an endothelial monolayer and restoration of stromal hydration to physiological thickness, demonstrating the feasibility of cell therapy in the treatment of corneal endothelial decompensation in a human in vitro model.

PURPOSE To evaluate visual outcomes, endothelial graft thickness, and complications in microthin Descemet stripping automated endothelial keratoplasty (DSAEK). METHODS A prospective interventional cohort of 130 eyes of 114 consecutive patients underwent microthin DSAEK. Endothelial graft preparation included pachymetry-controlled stromal dehydration to reduce donor thickness between 550 and 530 μm by a custom airflow device, before a single-pass microkeratome dissection with a uniform cutting head of 350 μm to achieve microthin endothelial grafts (

Purpose Cataract shared care schemes involving community optometrists show wide variation in practice. We report on defined key performance indicators (KPIs) which improve accountability between stakeholders. Methods In this prospective study over nine months at a UK public hospital, we evaluated the outcomes of consecutive direct cataract referrals from community optometrists against two KPIs agreed under a service-level agreement between the Hospital Eye Service and community optometrists: (1) 85% of patients listed for cataract listing at first consultation; and (2) 90% postoperative feedback return rate on patients discharged to community optometrists. A detailed analysis on referral triage, surgical listing and postoperative form return rate is reported in this study. Results A total of 733 direct cataract referrals were received using a designated referral form of which 86% were listed for cataract surgery. The predominant reason for not listing was a failure to reach the visual threshold set by the local clinical commissioning guidelines. Out of 569 cataract surgical episodes, 402 (71%) patients were discharged on the same day of surgery to community optometrist follow up. Completed postoperative feedback was returned from 374 patients (93%). Conclusion Direct cataract referrals from accredited community optometrists led to a majority of patients receiving a definitive clinical decision during first consultation. Postoperative community follow up reduced hospital visits and allowed for convenient consultation closer to home following uncomplicated cataract surgery. A service-level agreement with an accreditation scheme measured against KPIs enhances the accountability of stakeholders involved in the cataract shared care scheme.

Background/aims To evaluate a community optometrist-delivered postoperative discharge scheme in patients who underwent same day discharge from the hospital eye service (HES) following cataract surgery. Methods A service-level agreement (SLA) was agreed between the HES, primary care trust and community optometrists in Cambridgeshire regarding community follow-up after cataract surgery. Patients undergoing uncomplicated surgery with no significant ocular comorbidity were eligible for same day discharge to community optometrists. Feedback return rate and unintended medical interventions were assessed using an electronic medical record system. Results Over a 23-month period, a total of 1492 of 2461 (60.6%) Cambridgeshire patients were discharged to the community on the day of cataract surgery. Complete postoperative feedback was available in 96.85% of these patients. Uneventful postoperative recovery was recorded in 93.77% of patients with 2.95% of patients re-referred. Rates of cystoid macular oedema, uveitis and raised intraocular pressure were 0.6%, 1% and 0.1%, respectively. No patients had sight-threatening complications in this study. Conclusions Postcataract surgery follow-up by community optometrists provides the advantages of care closer to home and avoids unnecessary hospital visits for patients undergoing uncomplicated cataract surgery.

The recent years have brought about a sea change in the field of corneal transplantation with penetrating keratoplasty being phased to newer lamellar keratoplasty techniques for a variety of corneal pathology. Improved and innovative surgical techniques have allowed selective replacement of diseased host corneal layers with pre-prepared healthy donor corneal lamellae for anterior corneal disorders such as keratoconus and posterior corneal disorders such as Fuch's corneal endothelial dystrophy. The results of lamellar techniques are encouraging, with rapid visual rehabilitation and vastly reduced risk of immune-mediated transplant rejection. The techniques of deep anterior lamellar keratoplasty and Descemet's stripping endothelial keratoplasty (DSAEK) continue to evolve with advent of femtosecond lasers and newer concepts such as pre-conditioned donor corneas for Microthin DSAEK and Descemet's membrane keratoplasty. This review describes the current developments in lamellar keratoplasty, including the futuristic approach using cell therapy to restore vision in corneal blindness.

We report an unusual case of a 36-year-old woman with severe atopic eczema who developed sudden-onset reduction of vision in the right eye following excessive eye rubbing 9 years after cataract surgery. Examination identified posterior capsule rupture with dislocation of the intraocular lens (IOL) posteriorly into the vitreous cavity in the right eye and posterior capsule rupture with mild dislocation of the IOL in the bag in the left eye. To our knowledge, this is the first reported case of simultaneous bilateral posterior capsule rupture following uneventful surgery and secondary to eye rubbing. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

To evaluate the effects of ablation diameter on long-term refractive stability and corneal transparency after photorefractive keratectomy (PRK).Long-term, prospective, follow-up study.One hundred twenty-three eyes treated between 1990 and 1993 at one institution as part of a number of ethical committee-approved clinical studies underwent long-term follow-up at 10 to 12 years after PRK.Photorefractive keratectomy was performed using the Summit Technology UV 200 and OmniMed Excimer lasers with either 4.0-mm (n = 36), 5.0-mm (n = 47), or 6.0-mm (n = 40) optical zones and either -3.0-diopters (D) or -6.0-D myopic spherical corrections, based on the original Munnerlyn algorithms.Refractive stability, refractive predictability, best spectacle-corrected visual acuity, and corneal haze.Refractive outcome at 1 and 10 to 12 years of follow-up was better with 6.0-mm treatments, especially for -6.0-D corrections (P0.001). The early hyperopic shift was significantly reduced with 6.0-mm zones, with less regression between 1 and 6 months, compared with 5.0- and 4.00-mm PRK, especially for -6.0-D corrections (P0.001). The postoperative refraction remained stable between 1 and 10 to 12 years in all groups. Objective measurements of haze were less with 6.0-mm compared with 4.0- and 5.0-mm treatments (P0.001). Night vision problems were significantly less with 6.0-mm PRK (P0.01). There was no evidence of progressive hyperopic shift, corneal ectasia, or late onset of corneal haze in any of the eyes during the follow-up period.Refractive stability was maintained between 1 year and 10 to 12 years after PRK with 4.0-, 5.0-, and 6.0-mm optical zones. A significant linear trend was observed in terms of refractive predictability, early hyperopic shift, regression, corneal transparency, and night haloes with better outcomes in PRK with a larger ablation zone. None of the eyes had sight-threatening complications such as ectasia or late-onset corneal haze during the follow-up.

To develop an in vitro human corneal model to evaluate stromal epithelial interactions following corneal refractive surgical procedures.Department of Academic Ophthalmology, Rayne Institute, St. Thomas' Hospital, London, United Kingdom.Fifty-six human donor corneas procured from the eye bank were placed in a specially designed acrylic corneal holder and were cultured using the air-interface organ culture technique for up to 4 weeks. Corneal refractive surgical procedures such as a simple epithelial defect, 4 diopter (D) and 9 D photorefractive keratectomy (PRK), 4 D and 9 D laser-assisted subepithelial keratectomy (LASEK), and 9 D laser in situ keratomileusis (LASIK) were performed on the model. Temporal events in epithelial and keratocyte cell kinetics were evaluated using digital imaging, confocal microscopy, and light microscopy. Two-way analysis of variance and Student t tests were used to assess statistical significance.Epithelial healing following PRK was completed by 92 hours +/- 10 (SD) at a rate of 0.58 +/- 0.45 mm2/hour. In LASEK, the epithelial flap was replaced by regenerating peripheral epithelium that showed significant delay in epithelial closure (120 +/- 5 hours) with prolonged latency (24 +/- 4 hours, P.0001) in comparison with PRK. The magnitude of keratocyte loss corresponded to ablation depth, and keratocyte regeneration was dependent on epithelial closure. In comparison, LASIK corneas showed a lesser percentage of keratocyte loss with poor recovery of keratocyte density in the stromal flap. Epithelial viability and keratocyte density were well preserved in the in vitro human model as observed in control corneas for up to 4 weeks.The temporal events in stromal epithelial interactions in the in vitro human model closely mimicked in vivo observations. The human model further avoided species-specific variations and provided a suitable test bed for evaluating newer algorithms and therapeutic regimens following refractive surgery.

OBJECTIVE: To evaluate long-term refractive stability of excimer laser myopic photorefractive keratectomy (PRK). DESIGN: A long-term (12 years) prospective follow-up study. PARTICIPANTS: Sixty-eight patients (56.6%) of the original cohort of 120 who participated in the first United Kingdom excimer laser clinical trial underwent detailed clinical assessment at 12 years after myopic PRK. INTERVENTION: Myopic PRK was performed using the Summit Technology UV 200 excimer laser with a 4-mm ablation zone. Patients were allocated to 1 of 6 treatment groups based on their preoperative refraction. Each group received one of the following spherical corrections: -2, -3, -4, -5, -6, or -7 diopters (D). Patients in each group received an identical treatment, and therefore, emmetropia was not the primary aim. MAIN OUTCOME MEASURES: Refractive stability, refractive predictability, best spectacle-corrected visual acuity (BSCVA), and corneal haze. RESULTS: The postoperative refraction remained stable at 12 years, with no significant change in mean spherical equivalent refraction between 1, 6, and 12 years. Seventy-five percent of patients who underwent a -2-D correction and 65% of patients who received a -3-D correction were within 1 D of intended correction at 12 years. Fifty-seven percent of the -4-D group and 50% of the -5-D group were within 1 D, and this was further reduced to 25% and 22% in the -6-D and -7-D groups, respectively. Four percent had residual corneal haze, and 12% had persistent nighttime halos at 12 years. Dry eyes were encountered in 3% of patients, and none of the eyes developed corneal ectasia in the long term. CONCLUSIONS: In myopic PRK, refractive stability achieved at 1 year was maintained up to 12 years with no evidence of hyperopic shift, diurnal fluctuation, or late regression in the long term. Corneal haze decreased with time, with complete recovery of BSCVA. Night halos remained a significant problem in a subset of patients due to the small ablation zone size.

Purpose To compare axial lengths and intraocular lens (IOL) power calculations obtained with the Zeiss IOLMaster® by 2 observers with different training grades and to assess the agreement between optical and acoustic biometry. Setting Department of Ophthalmology, Pembury Hospital, The Laser Eye Clinic, Kent, United Kingdom. Methods In this prospective study, optical biometry was performed twice in 79 patients: first by a qualified ophthalmic nurse and second by 1 of several health care assistants without formal nursing training. In the same group of patients, the qualified nurse also obtained ultrasonic measurements to compare the 2 clinical methods. Results There was a high correlation coefficient for axial length and IOL power measurements (0.99 each) between the experienced examiner and the inexperienced examiners. The coefficient of repeatability (2 SD) was 0.58 diopter (D) for IOL power (mean 0.04 D) and 0.07 mm for the axial length (mean 0.00 mm). The correlation coefficient of IOLMaster measurements with A-scan measurements done by the same experienced ophthalmic nurse was 0.97 for IOL power and 0.98 for axial length. The limits of agreement (mean ± 2 SD) were between +0.50 and −2.40 D for IOL power calculations and between +0.7 mm and −0.2 mm for axial length measurements. Conclusions Optical biometry showed excellent repeatability using different examiners regardless of their medical training. The agreement with ultrasonic measurements and the precision of the method need further evaluation.

PURPOSE To describe a novel surgical technique to produce thin endothelial grafts for Descemet stripping automated endothelial keratoplasty (DSAEK). METHODS Thirteen human cadaveric corneas in organ culture were randomized into conventional (n = 7) and microthin (n = 6) DSAEK groups. Grafts in the conventional DSAEK group were prepared using the conventional DSAEK technique of a single microkeratome pass with a 350-μm cutting head. Corneas in the microthin group were preconditioned to achieve a target central thickness of 530 μm before graft dissection with a 350-μm microkeratome head. Preconditioning involved stromal dehydration under pachymetric control using sterile airflow for 15-second increments. Donor and graft thicknesses were assessed with optical coherence tomography, and endothelial viability with trypan blue and alizarin red staining. RESULTS Mean endothelial graft thickness obtained using the microthin DSAEK technique was 106 μm (SD, 32 μm) compared with 177 μm (SD, 33 μm) obtained using conventional DSAEK technique (P = 0.0024). Donor preconditioning yielded a predicted reduction of 100 μm in graft stromal thickness at a rate of 1.5 μm/s and mean duration of 72 seconds. The average anterior lamella thickness (cut depth) obtained in microthin and conventional DSAEK groups were 424 and 431 μm, respectively (P = 0.84). There was no difference in endothelial viability between the 2 groups. There were no corneal perforations during graft preparation in this study. CONCLUSIONS Donor preconditioning by pachymetry-controlled stromal dehydration achieved significantly thinner endothelial grafts compared with the conventional DSAEK technique without compromise to endothelial viability or graft wastage.

Latanoprost, a prostaglandin analogue (PGF2), is a commonly used antiglaucoma medication.1 As plasma concentration is low following topical administration, systemic adverse effects are unlikely to occur.1 Studies carried out in asthmatic volunteers with topical prostaglandin PGF2 did not show any respiratory side effects.2 Systemic administration of PGF2 has significant cardiac effects3,4,5 and it has a role in the mediation of sensory (pain) perception.6 Such side effects have not been reported with topical use. We report five cases of chest tightness following the use of latanoprost eye drops.

PURPOSE To develop a contact lens capable of releasing antibiotics for a minimum of 8 hours for the treatment of bacterial keratitis. METHODS Fibrin gel was loaded with vancomycin or gentamicin and then shaped into a curved disc. The disc was then used to coat the surface of a commercial contact lens or was sealed between two lenses. Separate contact lenses were soaked in solutions of vancomycin or gentamicin. The in vitro release kinetics for each system was determined using PBS at 37°C and a particle-enhanced turbidimetric inhibition immunoassay. The bioactivity of the antibiotics released from the fibrin was confirmed by using a microbiological assay. RESULTS Vancomycin and gentamicin were released at similar rates from soaked contact lenses and a coating of fibrin gel; however, the amounts of antibiotic delivered by the two systems differed considerably. The fibrin coating released over three times more gentamicin but less than one-fifth that of the lenses soaked in vancomycin. When fibrin was encapsulated between two contact lenses, significantly more controlled release was observed. For all systems, bactericidal amounts of vancomycin and gentamicin were released throughout the three-day testing period. CONCLUSIONS As a delivery system, fibrin gel loaded with gentamicin performs better than contact lenses soaked in gentamicin. The opposite is true for vancomycin, where soaked lenses outperform fibrin gel. These systems could potentially be used as a treatment for bacterial keratitis.

Congenital corneal anaesthesia (CCA) is an uncommon condition difficult to diagnose. We report the case of a 20-month-old boy who presented with unilateral congenital corneal anaesthesia. The child was referred with a persistent corneal epithelial defect, unresponsive to symptomatic local treatment for over 10 months. Intensive topical treatment and strict corneal protection led to quick corneal healing. Congenital corneal anaesthesia occurs either alone or in association with neurological diseases or systemic congenital abnormalities. It is important to search for corneal anaesthesia in children with chronic ulcerations of the cornea and self-inflicted injuries. Early diagnosis and treatment are important due to the risk of poor visual prognosis. Management of CCA should aim for the prevention of epithelial defects and is a life-long process.

The diagnosis of functional visual loss—reduced visual performance in the absence of an organic cause—is usually made by exclusion. We conducted a pilot study to evaluate pupil perimetry in three patients (aged 14, 43 and 50) with visual field loss presumed to be functional on clinical grounds and having no cause identified by visual electro-physiology or magnetic resonance imaging. A modified automated perimeter was used to examine visual and pupil responses to a light stimulus (size 1.7°) presented at five locations in the visual field (fixation and in each of the four quadrants).In each patient, the pupil responses were normal in those test quadrants which showed apparent visual field loss.Pupil perimetry provides objective evidence for a diagnosis of functional visual field loss in selected patients and may circumvent the need for other investigations.

To report a case of Listeria monocytogenes sclerokeratitis and to review the literature.Case report.A 25-year-old non-contact lens-wearing male rugby player was referred with progressive infective sclerokeratitis unresponsive to topical antivirals and antibiotics. On examination, visual acuity was perception of light, and a large corneal abscess with overlying epithelial defect and hypopyon was present. The corneal lesion was cheesy white and raised with nasal scleritis. This raised the suspicion of a fungal keratitis. Empirical treatment with intensive topical antifungals was unsuccessful. A previous corneal scrape had been negative for bacteria and fungi. A corneal biopsy was performed, and Listeria monocytogenes was eventually isolated from enrichment culture. Antibiotic sensitivities showed it to be resistant to cefuroxime, methicillin, and ceftazidime but sensitive to all other antibiotics tested including ofloxacin. The treatment course was complicated by a corneal perforation that needed an emergency therapeutic penetrating keratoplasty. Five months later, best-corrected visual acuity was 6/9 + 4, with a clear functioning graft.Listeria monocytogenes is a rare cause of corneal/scleral infection in humans. It often runs an aggressive course and responds poorly to initial intensive antibiotic treatment despite favorable in vitro sensitivities. It can be difficult to culture, and we suggest a corneal biopsy with extended incubation to improve diagnostic yield.

Conclusions: These data demonstrate that it is possible to culture LESCs ex vivo in compliance with good manufacturing practice regulations. A set of objective outcome measures that confirm the efficiency of this technique in treating LESC deficiency is described. The widespread use of such standardized and objective outcome measures would facilitate a comparison between the different culture methods in use. Design: Prospective, noncomparative, interventional case series. Main Outcome Measures: Clinical parameters of LESC deficiency (loss of epithelial transparency, superficial corneal vascularization, epithelial irregularity, and epithelial breakdown), visual acuity, impression cytology and cytokeratin expression profiles, and in vivo confocal corneal confocal microscopy. Methods: Allogeneic (7 eyes) or autologous (3 eyes) corneal LESCs were cultured on human amniotic membrane. Tissue was transplanted to the recipient eye after superficial keratectomy. Impression cytology and confocal microscopy were performed 6 months after surgery with clinical follow-up to 13 months. Success was defined as an improvement in the defined clinical parameters of LESC deficiency, an improvement in visual acuity, the restoration of a more normal corneal phenotype on impression cytology, and the appearance of a regular hexagonal basal layer of cells on corneal confocal microscopy. Objective: To determine, using objective measures, the outcome of ex vivo cultured limbal epithelial stem cell (LESC) transplantation performed in compliance with good manufacturing practice using a novel culture system without 3T3 feeder cells. Participants: Ten eyes of 10 patients with profound LESC deficiency arising from chemical injury (4 eyes), aniridia (3 eyes), ectodermal dysplasia (1 eye), Reiger's anomaly with Pax6 haploinsufficiency (1 eye), and unknown cause (1 eye). Results: The success rate using this technique was 60% (autografts 33%, allografts 71 %). All patients with a successful outcome experienced an improvement in visual acuity of ≥ 2 lines Snellen acuity. Preoperatively, CK3+ and CK19+ cells accounted for 12± 2.4% (mean ± standard error of the mean) and 80± 2.15% of cells, respectively, whereas postoperatively these accounted for 69± 6.43% (P< 0.0001) and 30± 6.34% (P< 0.0001) of cells, respectively. Goblet cells accounted for 8 ± 1 . 19% of cells preoperatively and 1 ± 0.35% of cells postoperatively (P< 0.0001).

To evaluate interocular differences in axial length and its relation to increasing axial length and postoperative refractive predictability in patients with age-related cataract.Moorfields Eye Hospital, London, United Kingdom.Preoperative biometry and postoperative refractive outcomes were analyzed in a consecutive series of 1537 patients who had uneventful bilateral phacoemulsification. In 1379 patients with bilateral data, the difference in axial lengths between eyes and the magnitude of postoperative anisometropia were compared between 1.0 mm incremental groups of axial length using the longer eye as the index eye. The postoperative refraction prediction error in 1457 left eyes was assessed in similar axial length groups.The difference in axial length was 0.3 mm or greater in 331 patients (24%). Axial length asymmetry between eyes increased with an increase in axial length in the index eye (P.001). The 95th centile of the axial length difference was 0.5 mm when the longer eye was 22.0 mm or less and 4.0 mm when it was 28 mm or greater. There was also an increase in postoperative anisometropia with increasing axial length (P = .003). The median was 0.34 D (interquartile range [IR], 0.25-1.11) when the longer eye had an axial length of less than 28.0 mm and 0.66 D (IR, 0.16-0.66) when the longer eye had an axial length of 28.0 mm or more. In left eyes, there was an increase in biometry prediction error with an increase in axial length (P = .006).An increase in axial length was associated with greater asymmetry between eyes and more postoperative anisometropia, especially in eyes with an axial length greater than 28.0 mm.

To investigate the effects of mitomycin-C (MMC) on epithelial and keratocyte cell kinetics after photorefractive keratectomy (PRK) using an in vitro human cornea model.Department of Academic Ophthalmology, Rayne Institute, St. Thomas' Hospital, London, United Kingdom.Twenty-four human eye-bank corneas were placed in a specially designed acrylic corneal holder and cultured using the air-interface organ culture technique for up to 4 weeks. The corneas were divided into 3 groups. Group 1 consisted of 8 human corneas that had -9.00 diopter (D) myopic PRK without MMC application. Group 2 consisted of 8 corneas that had -9.00 D PRK with MMC (0.2 microg/mL) application for 1 minute on the stromal surface after ablation. Group 3 consisted of 8 corneas that had -9.00 D PRK with 2-minute exposure to MMC (0.2 microg/mL). Temporal events in epithelial and keratocyte cell kinetics were evaluated using digital imaging, confocal microscopy, and light microscopy.Epithelial latency was significantly delayed with MMC application in Groups 2 and 3 (P.001). Epithelial migration was delayed in Group 3 (2-minute exposure) compared to migration in Group 2 (P.04), with a consequent delay in epithelial closure (P.001). Group 3 corneas had poorly differentiated epithelium that was significantly thinner than in Groups 1 and 2 (P.0001). A significant delay in keratocyte regeneration occurred after MMC application (P.0005). At 4 weeks, the anterior stromal cell density was significantly lower in Group 3 than Group 2 (P.001). There were no significant differences in the mid- and posterior stromal keratocyte density between the groups.Results suggest that epithelial healing after MMC is characterized by prolonged latency and decreased migration rate dependent on exposure time. Mitomycin C application did not result in increased loss of keratocytes, but it significantly delayed keratocyte repopulation in the anterior stroma. The use of MMC 0.2 microg/mL for 1 minute resulted in optimum modulation of healing characterized by reduced keratocyte activation with normal epithelial differentiation.

To assess topography-assisted corneal wavefront excimer laser surface ablation for the correction of ametropia and irregular astigmatism after keratoplasty.Department of Ophthalmology, St. Thomas' Hospital, London, United Kingdom.In this pilot study, 15 patients (16 eyes) who were intolerant of spectacle and contact lens correction due to astigmatic anisometropia after keratoplasty (15 penetrating and 1 lamellar) had topography-assisted customized excimer laser treatments. Corneal topographic data using a Keratron Scout, Placido disk system allowed for preoperative analysis of wavefront anomalies of the anterior corneal surface from which a customized excimer laser correction of both lower-order aberrations (LOAs) and higher-order aberrations (HOAs) was prepared (ORK software) for treatment with a Schwind Esiris flying-spot laser. All eyes had laser-assisted subepithelial keratectomy (LASEK) using 15% alcohol with a 20-second to 30-second application. Four eyes received an application of mitomycin-C (MMC) 0.2 mg/mL for 1 minute after stromal ablation.The mean preoperative spherical equivalent (SE) was -3.50 diopters (D) +/- 3.97 (SD) (range +1.625 to -9.25 D). The preoperative cylindrical error was -7.2 D (range -2.75 to -13.5 D). The programmed laser correction was -3.14 D (range +1.62 to -9 D) with a maximum attempted cylindrical correction of -7 D. Adherent LASEK epithelial flaps along suture lines and the graft-host junction were noted in 9 eyes (56%), although it was possible to obtain and replace a partial flap. A follow-up of 18 months was achieved in all eyes. At the final follow-up visit, the mean postoperative SE was -1.08 +/- 1.85 D (range +3 to -4.78 D) (P.01, F.01). Ten eyes (62.5%) were within +/-1 D of the intended correction. The mean postoperative cylindrical error was -2.72 D (range -0.5 to -6.5 D) (P.001), with vector analysis demonstrating a mean 6.23 D correction. Analysis of HOAs using a 6.0 mm pupil size demonstrated a significant reduction of higher-order root mean square (RMS) (P.002), trefoil (P.005), and 4th-order spherical aberration (P.02) at 18 months compared with preoperative values. Uncorrected visual acuity improved in all eyes (P.0001). Best spectacle-corrected visual acuity was unchanged or improved in 13 eyes (81%) and worse in 2 eyes by 1 line; 1 eye lost 3 lines due to an increase in preexisting cataract. In eyes that did not receive MMC, corneal haze (grade II to IV) was encountered in 3 eyes (27%). One eye required phototherapeutic keratectomy with MMC application at 12 months. Of the 4 eyes treated with MMC, 1 had trace haze and 3 had no detectable haze. There were no reported cases of epithelial instability, ectasia, or graft rejection.Topography-assisted customized LASEK was effective in the correction of postkeratoplasty astigmatism. A significant improvement of both LOAs and HOAs was obtained with good refractive stability for over 18 months. Iatrogenic haze typically occurred but appeared to be minimized with adjunctive use of intraoperative MMC.

Purpose To assess the long-term efficacy and stability of LASIK for hyperopia (+0.75 to +7.00 diopters [D]). Design Retrospective follow-up study of a previous phase III multicenter clinical trial (unpublished data). Participants Patients who had been treated for hyperopia (33 individuals, 47 eyes) attended follow-up 5 years after surgery. The preoperative mean spherical equivalent at the spectacle plane was +3.58 D (range, +0.75 to 7.00 D), and the attempted mean spherical correction at the corneal plane was +3.18 D (range, +1.00 to +6.00 D). Intervention Treatments were performed using a Moria LSK One microkeratome and a Summit Technology SVS Apex Plus excimer laser fitted with an Axicon. Main outcome measures Manifest refraction, uncorrected visual acuity, best spectacle-corrected visual acuity, corneal transparency, complications, and patient satisfaction were recorded. Results At 5 years, for treatments between +1.00 to +3.00 D, 71.0% of eyes were within ±1.00 D of the intended correction, and for treatments between +3.5 to +6.0 D, 37.5% of eyes were within ±1.00 D of intended correction. From 12 to 54 months after surgery for all patients, there was a hyperopic shift of +0.53 D (range, −0.13 to +3.13 D), with 51.1% of eyes experiencing an increase of +0.50 D or more and 27.7% of eyes showing a hyperopic shift of more than +1.00 D. This hyperopic shift was +0.67 D (range, 0 to +1.125 D) for patients younger than 40 years of age and +0.44 D (range, −1.33 to +1.50 D) for patients between 43 and 55 years of age. Conclusions LASIK was moderately effective for the correction of low degrees of hyperopia. However, there was regression throughout the 5-year follow-up that was greater than would be expected as a result of aging. Long-term stability of hyperopic LASIK refractive corrections, therefore, is uncertain.

Purpose: To investigate the effect of topical keratinocyte growth factor (KGF) on wound healing after photorefractive keratectomy (PRK) and laser in situ keratomileusis (LASIK). Setting: Department of Ophthalmology, Rayne Institute, St. Thomas' Hospital, London, United Kingdom, St. Erick's Eye Hospital, Stockholm, Sweden, and the University of Regensberg, Regensberg, Germany. Methods: In a placebo-controlled trial, 24 New Zealand white female rabbits were divided into 3 equal groups. Group 1 (n = 8) had myopic PRK (6.0 diopters [D]) using the Technolas® 217z laser (Bausch & Lomb). Group 2 and Group 3 had myopic LASIK (6.0 D) with a flap depth of 140 μm and 180 μm, respectively. Topical KGF (20 μg/mL) was administered to half the treated eyes in each group intraoperatively and postoperatively; the other half received placebo eyedrops. Epithelial closure, corneal haze, and keratocyte activation in the rabbit eyes were analyzed and compared with those in placebo-controlled eyes for 5 weeks postoperatively. Results: In Group 1, the mean reepithelialization after PRK was 0.10 mm2/h ± 0.02 (SD) in the KGF group and 0.33 ± 0.05 mm2/h in the control group (P = .001). There was no significant difference in the mean backscatter between the KGF eyes (154 ± 45.95) and the control eyes (141 ± 38.45) after PRK (P = .42). Histology revealed reduced epithelial cell layers in the KGF group and comparable keratocyte density as in the control group. In Groups 2 and 3, there was no significant difference in backscatter, epithelial layers, and keratocyte density between KGF and control eyes after LASIK. Conclusions: Topical KGF (20 μg/mL) delayed reepithelialization after PRK. It had no effect on stromal wound healing in LASIK eyes with an intact epithelial barrier.

The purpose of the study was to compare optical biometry based on partial coherence laser interferometry (PCLI) principle to conventional ultrasound biometry in the accuracy of intraocular lens (IOL) power calculations. The role of partial coherence laser interferometry in pseudophakic axial length measurement was analysed in the study.In a prospective randomised clinical trial, 100 patients undergoing phacoemulsification cataract surgery were randomised to undergo biometry by either partial coherence laser interferometry (IOL Master) or the applanation ultrasound technique. The IOL material, design and the IOL formula were standardized. The mean error and mean absolute error were calculated and compared using paired t-tests.One hundred patients were included in this prospective randomised trial, of whom 50 patients underwent optical biometry and 50 patients had biometry by applanation ultrasound. The mean age of patients in the PCLI group was 67 +/- 6 yrs as compared to 71 +/- 8 yrs in the ultrasound group (P0.05). The preoperative mean axial length was 23.47 +/- 1.1 mm in the PCLI group (range 20-27.6 mm) and 23.43 +/- 1.2 mm in the ultrasound group with a range of 20.1-27 mm (P0.05). The mean absolute error (MAE) in the PCLI group was 0.52 +/- 0.32 D (upper and lower 95% CI 0.62 and 0.42 respectively). The MAE in the ultrasound group was 0.62 +/- 0.4 D (upper and lower CI 0.73 and 0.50 D respectively). Eighty-seven per cent of patients were within +/- 1 D in the PCLI group as compared to 80% in the ultrasound group (P = 0.24). The MAE of axial length difference with optical biometry was 0.13 mm +/- 0.13 SD (range -0.42 to 0.78 mm) in the PCLI group and 0.19 +/- 0.13 mm in the ultrasound group. There was a mean shortening of the eye length in the PCLI group postoperatively. Optical biometry improved the post op refraction by 16% on retrospective IOL power calculations. Eight per cent failed biometry with IOL Master (dense cataracts (4%) and fixation instability due to macular degeneration (4%)).The non contact optical biometry using the partial coherence laser interferometry principle improves the predictive value for postoperative refraction and is a reliable tool in the measurement of intraocular distances in pseudophakic eyes.

Focal myositis (of Heffner) in the right trapezius and paraspinal muscles accompanied by a pseudotumour of the left orbit has not been reported previously. The clinical, pathological and radiological features of these unusual benign pseudotumours of the head and neck are discussed. Computerized tomography (CT) scan of the neck and orbital ultrasound were suggestive of an inflammatory process without an abscess formation. This was followed by fine needle aspiration cytology (FNAC), which confirmed the diagnosis. The patient was treated with intravenous steroids and antibiotics, that led to complete resolution of symptoms, and there was no recurrence at six months follow-up. This report highlights the importance of imaging in inflammatory neck swellings.

We describe a real time polymerase chain reaction (PCR) technique for the detection of treponemal DNA in the vitreous of patients with suspected syphilitic uveitis. A 41 year old white homosexual male presented with a 1 week history of pain, redness, and reduced visual acuity in the right eye. There was a recent history of mouth ulcers and skin rashes involving the left lower limb. Corrected Snellen visual acuities were 6/60 and 6/6 in the right and left eyes respectively. In the right eye there were 4+ cells in the anterior chamber and vitreous. The right optic disc was swollen with patchy retinitis involving the inferior quadrants. The left eye was normal. Treponema specific serology tests, total antibody enzyme immunoassay assay (EIA) and Treponema pallidum particle agglutination test (TPPA) were strongly positive. Rapid plasma reagin (RPR) titre was 1:512, consistent with active treponemal infection. Subsequent cerebrospinal fluid analysis was also positive for both RPR and TPPA, …

Cystoid macular edema (CME) is the most common cause of visual loss following uncomplicated cataract surgery and although the condition usually resolves itself within several months, it can result in permanent vision loss in a minority of patients. There is a lack of consensus in diagnostic methods and definition of the condition and as a result, estimates of its incidence vary greatly, ranging from 4 to 41 %. There is also a scarcity of randomised controlled trial data to support the efficacy of ophthalmic agents in the prophylaxis and treatment of CME. However, a growing body of evidence supports the use of topical non-steroidal anti-inflammatory drugs (NSAIDs) both pre-and post-surgery. The importance of the prophylactic use of NSAIDs should be emphasized as many cases of CME are preventable. The combination of corticosteroids and NSAIDs may be more effective than either class of agents alone. The use of bromfenac for the treatment and prevention of CME is growing. Its unique chemical structure makes it highly lipophilic with rapid penetration of ocular tissues; it has sustained anti-inflammatory action and allows less frequent dosing (twice a day as opposed to three or four times a day). This article presents four case studies detailing rapid CME resolution following topical administration of bromfenac.

Cytomegalovirus (CMV) retinitis in children with congenital CMV infection is known to differ from that described in immunocompromised subjects, because it is present at birth and does not progress postnatally if the child is otherwise immunocompetent. Regarding treatment, there are limited data in infants with symptomatic congenital CMV infection and it is not known whether antiviral drugs alter the prognosis. We describe a case of congenital CMV retinitis that progressed postnatally and our treatment regimen. A 9 day old baby was referred to the eye clinic after having been diagnosed with congenital symptomatic CMV infection. During pregnancy, at 34 weeks, poor growth and ventriculomegaly were noted and a scan at 35 weeks showed bilateral cysts in the occipital horn of the lateral ventricles. He was born at 40 weeks by emergency caesarean section. The mother was a healthy 18 year old woman. His birth weight was 2.1 kg and his head circumference 31.5 cm, both of which were below the 0.4th centile. Brain magnetic resonance imaging confirmed the presence of bilateral occipital cysts and periventricular calcification. Serology and urine tests showed congenital CMV infection. The child had a normal immune system for his age. Eye examination revealed sheathing of the retinal vessels and haemorrhages, which involved the arcades and were more marked in the left eye (Fig 1A, B, C). Exudates were present in both eyes superior to the disc (Fig 1A). The following day the vasculitis in the left eye had progressed and was involving the macula. Treatment with ganciclovir 5 mg/kg/day intravenously was started in view of the active retinitis. One week after …

Purpose To assess the long-term safety, predictability, and efficacy of wavefront-guided laser in situ keratomileusis (LASIK) retreatment in myopes and hyperopes following primary wavefront-guided LASIK. Design Retrospective nonrandomized case series. Methods Wavefront-guided retreatment was performed by a single surgeon (D.G.). A cohort of 63 eyes of 41 patients were studied, investigating refractive outcome, uncorrected visual acuity (UCVA), and best-corrected visual acuity before and after wavefront-guided LASIK retreatment. Results The mean spherical equivalent (MSE) prior to primary LASIK in the myopic group (46 eyes) was −5.4 ± 2.5 diopters (D) (range, −1 to −11.25 D). After the final retreatment the MSE was −0.08 ± 0.45 D (range, +1.25 to −1.25) with 82.6% achieving ±0.5 D and 95.6% ±1 D of emmetropia. The initial MSE in the hyperopic group (17 eyes) was +1.91 ± 1.13 D (range, +0.25 to +5.73 D). After the final retreatment the MSE was +0.23 ± 0.43 D (range, −0.5 to +1.25) with 88.2% achieving ±0.5 D and 100% ±1 D of emmetropia. Logarithm of the minimal angle of resolution UCVA was 0.22 ± 0.21 prior to primary LASIK and −0.06 ± 0.13 after final retreatment for myopes and 0.14 ± 0.15 prior to primary LASIK and 0.06 ± 0.16 after final retreatment for hyperopes. The mean follow-up time after LASIK enhancement was 17.75 months in the myopic and 14.6 months in the hyperopic group. Conclusion Our results suggest that wavefront-guided retreatment following initial wavefront-guided treatment in myopes and hyperopes has favorable outcome with respect to safety, predictability, and efficacy.

Cornea diseases are a leading cause of blindness and the disease burden is exacerbated by the increasing shortage around the world for cadaveric donor corneas. Despite the advances in the field of regenerative medicine, successful transplantation of laboratory‐made artificial corneas is not fully realized in clinical practice. The causes of failure of such artificial corneal implants are multifactorial and include latent infections from viruses and other microbes, enzyme overexpression, implant degradation, extrusion or delayed epithelial regeneration. Therefore, there is an urgent unmet need for developing customized corneal implants to suit the host environment and counter the effects of inflammation or infection, which are able to track early signs of implant failure in situ. This work reports a nanotoolbox comprising tools for protection from infection, promotion of regeneration, and noninvasive monitoring of the in situ corneal environment. These nanosystems can be incorporated within pro‐regenerative biosynthetic implants, transforming them into theranostic devices, which are able to respond to biological changes following implantation. Funding agencies: EU H2020 Marie Sklodowska-Curie Individual Fellowship [706694]; MIIC Strategic Postdoc Grant; MIIC Seed Grant at Linkoping University (LiU), Sweden