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Ocular chemical burns are produced by irritants, acids or alkalis. Their severity depends on the type of the causative chemical substance, its concentration, its physical form, the duration of contact, the ocular surface area affected and the delay in medical attention. Severe cases can be difficult to manage posing a challenge for general practitioners and ophthalmology specialists. This review aims to describe a protocol of action for their immediate management since they are ophthalmic emergencies which can lead to fatal ocular consequences without adequate medical treatment, impacting on the health, quality of life and labor productivity of the patient.

Purpose To describe the visual, refractive, topographic and aberrometric outcomes of six different accelerated cross-linking (ACXL) protocols in progressive keratoconus (KC) at 12 months. # Material and methods This observational retrospective study included 62 eyes of 49 patients with progressive KC that received one of the following accelerated cross-linking protocols: Group I (8 patients, 5.4 J/cm2, 15mWx12min, pulsed), Group II (11 patients, 5.4 J/cm2, 6mWx15min, continuous), Group III (16 patients, 5.4 J/cm2, 9mWx10min, continuous), Group IV (13 patients, 5.4 J/cm2, 30mWx6min, pulsed), Group V (8 patients, 7.2 J/cm2, 15mWx16min, pulsed) and Group VI (6 patients, 7.2 J/cm2, 30mWx8min, pulsed). Best corrected visual acuity (BCVA), sphere, refractive cylinder, spherical equivalent (SE), maximum keratometry (Kmax), mean keratometry (Km), flat keratometry (K1), steep keratometry (K2), thinnest pachymetry, total aberrations, high order aberrations (RMS-HOA), spherical aberration, coma and trefoil were studied previously and at 12 months. Intragroup and intergroup statistical analysis was performed. Postoperative complications were noted. # Results 11 patients were females(22,45%) and 38 males(77,55%). Improvement in the BCVA was observed in all groups (P > 0.05). Kmax reduced in all patients and was statistically significant in groups II (p = 0.041), III (p = 0.017), IV (p = 0.018) and V (p = 0.018). Flattening of the Km was significant in groups II (p = 0.028), IV (p = 0.008) and V (p = 0.028), as well as the K1 in groups IV(p = 0.01) and V(p = 0.028) and K2 in group IV(p = 0.036). There was no significant difference in the thinnest pachymetry in any of the groups. Total aberrations, RMS-HOA, spherical aberration and coma reduced in all groups with statistical significance in Group V (P = 0.016). Two patients in Group I had anterior stromal scarring and one patient in Group V presented an unexpected overflattening. Progression was noticed in one patient in Group II. # Conclusions Accelerated CXL protocols included in this study can be considered effective and safe procedures in stopping the progression of keratoconus at 12 months. Improvement in BCVA and wavefront analysis is observed, but results are limited by the number of patients. Caution should be taken when applying high radiance and long duration protocols to prevent undesirable events.

Peripheral ulcerative keratitis (PUK) is a group of corneal disorders that cause peripheral corneal thinning, threatening globe integrity in advance stages. It is usually associated with systemic autoimmune diseases and management is based on local and systemic approaches. We present the case of a 47-year-old man with a previous history of bacterial keratitis in his left eye presenting with 1 month of bilateral ocular pain and redness. At examination, diffuse bilateral globe inflammation with paracentral corneal thinning in his left eye was observed. He was diagnosed with bilateral scleritis and PUK in his left eye. Workup for associated systemic autoimmune disease yielded negative results. The patient was started on pulses of intravenous methylprednisolone followed by oral prednisone failing to achieve sufficient control of the inflammatory syndrome. Subsequently, periodic intravenous cyclophosphamide was administered with a favorable response. A multilayer amniotic membrane graft was applied, but there was rapid melting with reabsorption of the tissue, resulting in extreme corneal thinning at the inferior paracentral cornea. A decentered 8.5-mm superficial anterior lamellar keratoplasty (SALK) was then performed obtaining the donor graft with a femtosecond laser but performing manual trepanation in the recipient. At 12 months, visual and biomicroscopic measures do not show deterioration and inflammation remains under control with oral azathioprine as maintenance regime. The management of PUK includes both systemic immunosuppression and tectonic procedures to preserve the globe integrity. Diverse surgical techniques have been attempted, but no definitive guidelines are available. Decentered large SALK is a simple technique that can yield acceptable visual results.

This is a report of a case of severe intraocular infammation associated with cytomegalovirus in an untreated HIV+ patient with a marked CD4+ T-cell depletion. The atypical presentation shown could confuse and delay the diagnosis. Early suspicion and appropriate treatment (ganciclovir, valganciclovir, HAART) increase the likelihood of a favourable outcome.

Purpose: To report 2 cases of refractory idiopathic scleritis treated with rituximab.Design: Interventional case series.Methods and Results: Case 1: A 54-year-old woman, presented with anterior idiopathic scleritis in her right eye. Treatment with systemic steroids was not effective. Intravenous cyclophosphamide was discontinued after an adverse event. Case 2: A 43-year-old woman presented with idiopathic posterior scleritis in her left eye. Initial treatment with steroids was ineffective. In both cases, long-lasting remission without further relapses was achieved after 4 weekly doses (375 mg/m2) of rituximab.Conclusion: Rituximab was found to be an effective treatment for refractory idiopathic anterior and posterior scleritis.

Based on the relationship between keratoconus and dry eye, the aim of this study was to evaluate changes in signs and symptoms of dry eye in keratoconus patients before and after intrastromal corneal ring surgery.Fifteen keratoconus patients were enrolled in Fundación Jiménez-Díaz of Madrid and University Clinic of Optometry of the Universidad Complutense de Madrid (Madrid, Spain). Tear break up time (TBUT), Schirmer test without anesthesia, corneal staining, diadenosine tetraphosphate (ApWe found no statistical differences in time in Schirmer test, TBUT, and corneal staining. OSDI scores were 44.96 ± 8.65, 26.30 ± 6.79, and 19.31 ± 4.28 for (pre), (post), and (post6m) surgery, respectively (p0.001). Impression cytology showed a decrease in cell density at (post6m) compared with presurgery (47.36 ± 35.15 cells/mmIntrastromal corneal ring surgery induces changes improving dry eye symptoms but no changes were found in signs of dry eye after surgery in keratoconus patients except for the MCH that increases drastically. More studies are needed to clarify the reason of its improvement.

To compare signs and symptoms of dry eye in keratoconus (KC) patients versus healthy subjects.A total of 15 KC patients (KC group, n = 15 eyes) and 16 healthy subjects (control group, 16 eyes) were enrolled in this study. The Schirmer I test with no anesthetic, tear break-up time (TBUT), corneal staining characteristics, and ocular surface disease index (OSDI) scores were evaluated for both groups. Impression cytology, combined with/scanning laser confocal microscopy (LCM), was performed to evaluate goblet cell density, mucin cloud height (MCH), and goblet cell layer thickness (CLT). Finally, tear concentrations of di-adenosine tetraphosphate (Ap4A) were assessed. Results were statistically analyzed using Shapiro-Wilk and non-parametric Wilcoxon rank sum tests. Statistical significance was set at p 0.05.KC patients had lower tear volumes and greater corneal staining than did healthy subjects (p 0.05). OSDI scores were 44.96 ± 8.65 and 17.78 ± 6.50 for the KC and control groups, respectively (p 0.05). We found no statistically significant differences in TBUT between groups. Impression cytology revealed lower goblet cell densities in KC group patients versus control group subjects (84.88 ± 32.98 and 128.88 ± 50.60 cells/mm,(2) respectively, p 0.05). There was a statistically significant reduction in MCH and CLT in KC group patients compared with control group subjects. Ap4A tear concentrations were higher in KC group patients than in control group subjects (2.56 ± 1.10 and 0.15 ± 0.12 µM, respectively, p 0.05).The parameters evaluated in this study indicate that KC patients suffer greater symptoms of dry eye and greater tear instability, primarily due to the decreased mucin production in their tears, than do healthy patients with no KC.

Objective The aim of this study was to describe a family with cryopyrin-associated periodic syndrome (CAPS) in which the disease was unveiled after the ophthalmologic evaluation. Methods Family and personal histories from each of the patients were recorded. Each underwent a full ophthalmological examination along with the physical examination. The mutational analysis of the NLRP3 gene was performed by means of direct sequencing. Results The proband was admitted during an episode of unilateral anterior uveitis. She had a history of recurrent red eye and had been suffering episodes of skin rash and arthralgia induced by cold since childhood. At examination, she showed a reticulated corneal mid-stroma. Her mother and her younger sister also suffered from relapsing episodes of skin rash and fever triggered by cold as well as flares of red eye. They had developed premature hearing loss. In both cases, opacities in the corneal mid-stroma were evidenced with a slit lamp. The genetic analysis detected the heterozygous germline p.R260W mutation in the NLRP3 gene in the three women, confirming the diagnosis of CAPS. Treatment with anakinra resulted in complete remission of flares. Conclusion In this family, a structural NLRP3 mutation was associated with classic MuckleWells features of different degrees of severity. Interstitial keratitis with corneal opacification, usually ascribed to neonatal-onset multisystem inflammatory disease, was found. We underscore that ocular involvement in MuckleWells syndrome should be carefully assessed, since it can lead to visual impairment.