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To show our results with the use of topical tacrolimus in pediatric patients with anterior segment inflammatory disorders. Retrospective case series review of pediatric patients treated with 0.03% topical tacrolimus ointment into the conjunctival sac once a day. All patients treated between 2015 and 2020 were included. Primary outcome was clinical improvement defined as a reduction in the clinical sign score in the last visit. Secondary outcome was a reduction in the topical steroidal treatment. A total of 12 patients with a mean age of 9 years were included. The average follow-up time was 23 months. The mean duration of tacrolimus use was 19.6 months. Clinical improvement was seen in 11 patients (92%) with a significant reduction in the mean clinical score from 4.5 baseline to 0.6 (P= 0.0002) and steroid reduction was achieved in all cases. Two patients stopped tacrolimus during the follow-up period for poor effect. The use of topical conjunctival dermatological tacrolimus 0.03% ointment is an effective and safe treatment in children with external eye inflammation. Most of the patients presented clinical improvement and all steroid reduction with its use. The main side effect reported was discomfort with the application.

Purpose: To assess potential differences between central and eccentric cones in the aberrometric corneal profile and in visual and keratometric outcomes 6 months after intracorneal ring segment (ICRS) implantation for keratoconus. Methods: This study compared two groups consisting of 12 patients each, with central or eccentric keratoconus who were treated with femtosecond laser-assisted Keraring implantation. Uncorrected (UDVA) and corrected (CDVA) distance visual acuity, keratometric readings and higher order aberrations (HOAs) including high order aberrations root mean square (HOARMS), coma, spherical aberration and trefoil were measured preoperatively and 6 months after ICRS implantation. Results: Trefoil and spherical aberration were significantly reduced after ICRS implantation compared to preoperative values in eccentric keratoconus (Trefoil, p = 0.0049; Spherical aberration, p < 0.0001). In central keratoconus spherical aberration was reduced not significantly after ICRS implantation compared to preoperative values ( p = 0.087). Coma showed a significant reduction in central ( p = 0.0001) and in eccentric keratoconus ( p = 0.0001). The reduction of spherical aberration in central keratoconus was significantly positively correlated to improvement in UDVA (Pearson’s correlation coefficient, r = −0.66; p = 0.02). In eccentric keratoconus there was a significant positive correlation between reduction of trefoil and improvement in UDVA (Spearmans R, r = −0.69; p = 0.01). Conclusion: Patients both with central and eccentric keratoconus benefit from ICRS implantation. Specifically, our data provide a slightly higher gain in visual performance for eccentric cones 6 month after ICRS implantation, which is accentuated by a greater reduction in spherical aberration and trefoil. Improvements in UDVA are positively correlated with reductions in HOAs.

Two young children with upper lid colobomas and associated lipodermoids underwent eyelid reconstruction using lipodermoid skin as an autograft with good cosmesis. We describe their presentation, surgical management, and clinical progress following reconstruction, demonstrating the suitability of this skin as an adequate graft avoiding the need for further skin graft harvesting in such cases.

Mohamed Elalfy,1,2 Sundas Maqsood,1 Scott Hau,3 Ruben Y Kannan,4 Charles Nduka,4 Samer Hamada,1 Raman Malhotra1 1Corneo Plastic Unit, Queen Victoria Hospital, East Grinstead, UK; 2Research Institute of Ophthalmology, Giza, Egypt; 3Moorfields Eye Hospital, London, UK; 4Plastic Surgery Department, Queen Victoria Hospital, East Grinstead, UKCorrespondence: Mohamed ElalfyResearch Institute of Ophthalmology, El-Khalifa, Oula, Giza, 12557, EgyptTel +20235718304Email m.s.elalfy@gmail.comObjective: To report the functional and anatomical outcomes including structural changes in corneal nerve density and morphology using in vivo confocal microscopy (IVCM) after corneal neurotisation in patients with neurotrophic keratopathy (NK), using a sural nerve graft.Patients and Methods: Prospective study of patients undergoing corneal neurotisation for NK. Functional outcomes were measured through visual acuity, slit-lamp examination of corneal and conjunctival staining, tear production (Schirmer’s 1 test), tear film break-up time, tear film meniscus height, quality and osmolarity, central corneal thickness and corneal sensation using Cochet–Bonnet esthesiometry. Structural outcomes were assessed from changes in corneal nerve density and morphology with IVCM. Subjective outcomes were assessed using VFQ-25 and latest telephonic consultation.Results: Between February 2016 and April 2018, 11 corneal neurotisations were performed on 11 patients (3 males, 8 females). Median age was 43 (range 25– 62) years. Mean follow-up was 14.5 (range, 4– 36) months. Snellen visual acuity improved in 6 patients, corneal and conjunctival staining decreased in 10, tear film breakup time increased in 9, tear meniscus height increased in 7, Schirmers test readings increased in 4, tear film osmolarity reduced in 8 and central corneal thickness increased in 10 patients. Corneal sensation improved in nine patients. Complete IVCM data were available in five cases and demonstrated an improvement of corneal nerve density and length at 12 months.Conclusion: This series confirms the fact that the outcomes of this technique are reproducible and that corneal neurotisation surgery helps restore trophic nerve function more consistently than touch-related sensation.Keywords: corneal neurotisation, neurotrophic keratopathy, sural nerve, corneal sensations

Sundas Maqsood,1,2 Kareem Elsawah,3 Navpreet Dhillon,1 Shady Soliman,3 Masara Laginaf,2 Vaishali Lodhia,2 Damian Lake,1 Samer Hamada,1 Mohamed Elalfy1– 3 1Corneo-Plastic Unit, Queen Victoria Hospital NHS, East Grinstead, UK; 2Eye Department, Maidstone and Turnbridge Wells Hospitals, Maidstone, UK; 3Cornea Department, Research Institute of Ophthalmology, Giza, EgyptCorrespondence: Mohamed Elalfy Tel +44 1342 414560Email m.elalfy@nhs.netObjective: To report the outcomes of using human amniotic membrane-derived dry matrix (AMDDM) in the management of persistent corneal epithelial defects (PEDs) of various etiologies.Methods: A cohort study of 84 patients age range 7 to 92 years with 93 PEDs were treated with AMDDM (Omnigen® using OmniLenz® at two centers (Queen Victoria Hospital and Maidstone Hospital) in the UK. The main outcome measures were healing response of PED and time to heal after application of AMDDM.Results: A total of 106 applications of AMDDM were recorded for 81 patients (52 males, 29 females) with a spectrum of different etiologies. Fifty-eight percent of the eyes showed complete healing, and 28% showed partial decrease of the size of PEDs with average treatment length recorded as 22.4± 12.3 days. In patients with limbal stem cell deficiency (n=44; aniridia=12, chemical injury=9, Stevens–Johnson syndrome=10), 50% of PEDs showed complete healing and 27% showed partial healing. In patients with microbial keratitis (n=21) (bacterial: 13, fungal: 4, herpetic: 3, acanthamoeba: 1) 57% of PEDs showed complete healing and 33% were partially healed. In patients with keratoplasty (n=16), 56% of PEDs showed complete healing and 31% were partially healed. Vision remained stable in 59% and improved in 27% of the study the population.Conclusion: AMDDM can be easily applied in the clinical setting and has demonstrated its efficiency as a new tool to treat persistent epithelial defects.Keywords: persistent epithelial defects, amniotic membrane derived dry matrix, suture less amniotic membrane

Purpose Retrospective case series evaluating the efficacy and safety of implanting XtraFocus™ pinhole device in pseudophakic patients with irregular corneal astigmatism with concurrent or standalone iris defect. Methods Electronic case records were searched for: uncorrected distance visual acuities (UDVA) and corrected distance visual acuities (CDVA), automatic or manifest refraction and spherical equivalent (SE). All main outcomes were evaluated preoperatively and postoperatively at 1, 3, 6, 9 and 12 months, along with patients’ satisfactory outcome and complications. Results Eleven pseudophakic eyes of 11 patients with a mean age of 54 (range 27–81) years were included. Median UDVA improved significantly from logMAR 0.7 (range 0.1–1.22) pre-operatively to 0.4 (range 0–1.3) at 1-month (p = 0.002); median CDVA remained unchanged at logMAR 0.4 (range 0–0.1) pre-operatively and 0.4 (range 0–0.8) at 1-month (p = 0.36). There were no significant statistical differences in both UDVA and CDVA between the post-operative periods. Ten patients (90.9%) had initial UDVA improvement at 1-month post op. Eight (72.7%) patients expressed satisfaction with improved vision or reduction of glare/halos. Three (27.3%) patients had unsatisfactory visual outcome resulting in 2 requested for implant explantation due to worsening of glare and distressing floaters. Conclusions XtraFocus™ is effective in improving vision or reducing glare in pseudophakic patients with irregular corneal astigmatism or intragenic iris trauma, with over 70% expressed satisfactory outcome. Disturbing floaters and glare preclude its use in some resulting in implant explantation.

Summary Background The WHO VISION 2020 global initiative against blindness, launched in 2000, prioritised childhood visual disability by aiming to end avoidable childhood blindness by 2020. However, progress has been hampered by the global paucity of epidemiological data concerning childhood visual disability. The British Childhood Visual Impairment and Blindness Study 2 (BCVIS2) was done to address this evidence gap. Methods BCVIS2 was a prospective UK-wide, cross-sectional, observational study to establish an inception cohort of children newly diagnosed with visual impairment. Ophthalmologists and paediatricians reported cases from 89 hospitals and community centres across the UK. We included children aged 18 years or younger who were newly diagnosed with any condition causing impaired visual acuity to a level of 0·5 logMAR or worse (worse than 6/18 Snellen) in each eye, or equivalent vision as assessed by standard qualitative measures, between Oct 1, 2015, and Nov 1, 2016. Eligible children were notified simultaneously but independently by their managing ophthalmologists and paediatricians via the two national active surveillance schemes, the British Ophthalmological Surveillance Unit and the British Paediatric Surveillance Unit. Standardised detailed demographic, socioeconomic, and clinical data about detection, management, and treatment were collected at diagnosis and 1 year later. We calculated incidence estimates and relative rates by key sociodemographic factors. We did descriptive analyses of underlying ophthalmic disorders and non-ophthalmic comorbidities. Findings 61 (7%) of 845 eligible children initially notified were ineligible at follow-up because of improved vision after treatment. Thus, the study sample comprised 784 children with permanent newly-diagnosed all-cause visual impairment, severe visual impairment, or blindness. 559 (72%) of 778 children had clinically significant non-ophthalmic impairments or conditions. 28 (4%) of 784 children died within a year after diagnosis of visual disability (all had underlying systemic disorders). Incidence of visual disability in the first year of life was 5·19 per 10 000 children (95% CI 4·71–5·72), almost ten times higher than among 1-to-4-year-olds and between 20 times and 100 times higher than in the older age groups. The overall cumulative incidence (or lifetime risk) of visual impairment, severe visual impairment, or blindness was 10·03 per 10 000 children (9·35–10·76). Incidence rates were higher for those from any ethnic minority group, the lowest quintile of socioeconomic status, and those born preterm or with low birthweight. 345 (44%) of 784 children had a single affected anatomical site. Disorders of the brain and visual pathways affected 378 (48%) of 784 children. Interpretation BCVIS2 provides a contemporary snapshot of the heterogeneity, multi-morbidity, and vulnerability associated with childhood visual disability in a high-income country. These findings could facilitate developing and delivering health care and planning of interventional research. Our findings highlight the importance of including childhood visual disability as a sentinel event and metric in global child health initiatives. Funding Fight for Sight, National Institute for Health Research, and Ulverscroft Foundation.

A 41-year-old male presented with a large non-pigmented lesion on the ocular surface involving 8 clock hours of limbus, bulbar conjunctiva, and palpebral conjunctiva. Incisional biopsy confirmed poorly differentiated conjunctival squamous cell carcinoma (SCC). It was staged as a T3, N0, M0 lesion. Treatment was with surgical excision, amniotic membrane transplant, and buccal mucosa graft. Three weekly cycles of 0.04% mitomycin C were administered postoperatively. Six months following excision, although there was no evidence of residual conjunctival SCC, the patient suffered from poor vision, significant pain, and diplopia due to severe dry eye, limbal stem cell deficiency, and symblepharon.This case illustrates the difficult clinical decisions which confront the clinician when treating conjunctival SCC, particularly with balancing the need to eradicate the disease to prevent local invasion and metastatic spread on the one hand and minimising ocular morbidity on the other.

Purpose: To assess signs of dry eye syndrome in keratoconic eyes following intracorneal ring segment (ICRS) implantation. Patient and methods: Twenty eyes of 20 consecutive patients with keratoconus were assessed for tear film changes following ICRS implantation at 6 months postoperatively. Evaluated parameters included tear osmolarity, non-invasive tear breakup time test (NI-BUT test) and Schirmer test I and II before and after treatment. Results: No significant changes were found with respect to osmolarity, Schirmer I and II ( p = 0.9, p Conclusion: Our results suggest that implantation of ICRS does not result in a significant change in tear film osmolarity, or tear film volume nor improves the tear film stability.

The PERSPECTIVE study evaluated, in routine clinical practice, the effectiveness, tolerability and safety of cyclosporine A (CsA) 0.1% cationic emulsion (CE) in controlling severe keratitis in adults with dry eye who remained insufficiently controlled despite artificial tear (AT) use.A prospective, multicenter, observational study was conducted at 44 ophthalmology clinics across Finland, Germany, Norway, Sweden and the UK. Adults treated with ATs for severe keratitis and dry eye received CsA 0.1% CE therapy (1 drop in both eyes at bedtime) and were followed up at weeks 4, 12 and 24 and at month 12. Primary endpoint was mean [standard deviation (SD)] change from baseline in corneal fluorescein staining (CFS; Oxford Grade Scale) at month 12 following CsA 0.1% CE initiation. Secondary endpoints examined ocular sign and symptom severity and adverse events (AEs).The full analysis set included 472 adults (75.9% female). Mean (SD) age was 61.9 (15.41) years. Mean (SD) CFS score was significantly reduced from baseline [2.56 (1.10)] at month 12 [1.10 (SD 1.13); P 0.0001]. CFS score reductions were statistically significant from week 4, with further incremental decreases reported at study visits through month 12 (P 0.0001). Severity of eyelid and conjunctival erythema was significantly reduced from baseline at week 4 and maintained through month 12 (P 0.001). Tear film breakup time increased significantly from baseline at all study visits through month 12 (P 0.001). Ocular symptom severity was significantly reduced from baseline at all study visits through month 12 (P 0.001). Overall, 101 treatment-related AEs were reported. Most were mild/moderate (83.6%) and resolved by month 12 (73.3%).In routine clinical practice, CsA 0.1% CE provided statistically significant reductions in dry eye signs and symptoms. Improvements were seen at week 4 and maintained over 12 months. Treatment tolerability was good and consistent with previous CsA 0.1% CE clinical studies.EU PAS register number: EUPAS 22376.

While Keratoconus has been traditionally considered a predominantly degenerative, non-inflammatory disease, several studies suggest a pivotal role of the ocular surface inflammation in its pathogenesis and progression, modifying the original dogma. The role of ocular surface and tear film abnormalities in the pathophysiology and progression has been implied in keratoconic patients, alluding to a powerful link between Keratoconus and these elements, thus identifying potentially treatable risk factors for its progression.

Fungal keratitis (FK) is a serious ocular infection that often poses significant diagnostic and therapeutic dilemmas. This study aimed to examine the causes, clinical characteristics, outcomes, and prognostic factors of FK in the UK. All culture-positive and culture-negative presumed FK (with complete data) that presented to Queen’s Medical Centre, Nottingham, and the Queen Victoria Hospital, East Grinstead, between 2011 and 2020 were included. We included 117 patients (n = 117 eyes) with FK in this study. The mean age was 59.0 ± 19.6 years (range, 4–92 years) and 51.3% of patients were female. Fifty-three fungal isolates were identified from 52 (44.4%) culture-positive cases, with Candida spp. (33, 62.3%), Fusarium spp. (9, 17.0%), and Aspergillus spp. (5, 9.4%) being the most common organisms. Ocular surface disease (60, 51.3%), prior corneal surgery (44, 37.6%), and systemic immunosuppression (42, 35.9%) were the three most common risk factors. Hospitalisation for intensive treatment was required for 95 (81.2%) patients, with a duration of 18.9 ± 16.3 days. Sixty-six (56.4%) patients required additional surgical interventions for eradicating the infection. Emergency therapeutic/tectonic keratoplasty was performed in 29 (24.8%) cases, though 13 (44.8%) of them failed at final follow-up. The final corrected-distance-visual-acuity (CDVA) was 1.67 ± 1.08 logMAR. Multivariable logistic regression analyses demonstrated increased age, large infiltrate size (&gt, 3 mm), and poor presenting CDVA (&lt, 1.0 logMAR) as significant negative predictive factors for poor visual outcome (CDVA of &lt, 1.0 logMAR) and poor corneal healing (&gt, 60 days of healing time or occurrence of corneal perforation requiring emergency keratoplasty, all p &lt, 0.05). In conclusion, FK represents a difficult-to-treat ocular infection that often results in poor visual outcomes, with a high need for surgical interventions. Innovative treatment strategies are urgently required to tackle this unmet need.

Vernal keratoconjunctivitis is a chronic allergic conjunctivitis with corneal involvement that affects children and adolescents. Its pathogenic mechanisms are not entirely clear, but IgE and other inflammatory mediators are involved. An 8-year-old boy with vernal keratoconjunctivitis not responding to conventional treatment started immunotherapy with good results, decreasing the topical steroid dependence. Conventional vernal keratoconjunctivitis treatment involves topical antihistamines and steroids. These are not always effective and steroids can be associated with severe ocular complications in the long term. The authors suggest searching for possible allergens and starting immunotherapy associated with conventional topical treatment earlier, in addition to measuring the health-related quality of life by applying the Quality of Life in Children with Vernal Keratoconjunctivitis questionnaire and adjusting the treatment according to the impact on patients' quality of life. [ J Pediatr Ophthalmol Strabismus. 2021;58(5):e36–e39.]

Mucous membrane pemphigoid (MMP) is a systemic cicatrizing autoimmune disease that primarily affects orificial mucous membranes, such as the conjunctiva, the nasal cavity, the oropharynx, and the genitalia. Ocular involvement occurs in about 70% of all MMP cases. Ocular MMP (OcMMP) also encompasses the conditions linear immunoglobulin A disease, mucosal dominated epidermolysis bullosa acquisita, and anti-laminin 332/anti-epiligrin/anti-laminin 5 pemphigoid. It is a complex clinical entity that may lead to ocular surface failure and result in inflammatory and infectious complications, as well as potentially devastating visual loss. Early diagnosis and appropriate treatment are of paramount importance and require a high level of expertise as this condition can be extremely challenging to diagnose and treat even for experienced clinicians. In this review we provide an up-to-date insight on the pathophysiology of OcMMP, with an emphasis on the current state of its diagnostics and therapeutics. Our the aim is to increase our understanding of OcMMP and highlight modern diagnostic and therapeutic options.

Mohamed Elalfy, 1– 3,* Sundas Maqsood, 1,* Shady Soliman, 3 Sherif Momtaz Hegazy, 3Ahmed Abdou Hannon, 3 Zisis Gatzioufas, 1, 4 Damian Lake, 1 Samer Hamada 1 1Corneo Plastic Unit, Queen Victoria Hospital, East Grinstead, UK; 2Eye Department, Maidstone and Turnbridge Wells Hospital, Maidstone, UK; 3Research Institute of Ophthalmology, Giza, Egypt; 4Eye Department, University Hospital Basel, Basel, Switzerland*These authors contributed equally to this workCorrespondence: Mohamed ElalfyQueen Victoria Hospital, Holtye Road, East Grinstead, West Sussex, RH19 3DZ, UKTel +44 01342414560Email m.elalfy@nhs.netPurpose: To evaluate the incidence, demographics, associated risk factors, management and clinical outcomes of ocular hypertension/glaucoma after Descemet stripping automated endothelial keratoplasty (DSAEK).Methods: A cohort review of 81 DSAEK cases was performed at Queen Victoria Hospital, United Kingdom. Patients with pre-existing glaucoma, transient increased IOP within the first 48 hours post-graft, additional post-transplant surgery, or failed to complete one year follow-up were excluded from the study. Ocular hypertension was defined as intraocular pressure (IOP) elevation > 21mmHg or ≥ 6mmHg from baseline at any postoperative visit. The study looked at the incidence, risk factors, response to anti-glaucoma treatment, graft failure and best corrected visual acuity.Results: The incidence of post-DSAEK ocular hypertension and glaucoma was 51.9% and 13.6%, respectively. Steroid-induced IOP elevation was the most frequent cause, with an incidence of 38.3%. Risk factors such as pseudophakia (p=0.024) and preoperative IOP> 16 (p=0.003) were found to be associated with post-DSAEK ocular hypertension. Preoperative IOP> 16 had 5.27 times risk of IOP elevation. Eyes with graft dislocation and/or detachment were significantly associated with post-DSAEK glaucoma (p=0.038). There was no negative effect of OHT on visual acuity and graft status.Conclusion: Glaucoma and OHT are common postoperative complications of DSAEK. Although steroid-induced IOP elevation was the most frequent cause, there are other reasons associated with development of post-DSAEK glaucoma, including graft dislocation and detachment. Eyes with preoperative IOP> 16 mm Hg may require a close monitoring of IOP. In addition, management by medical treatment results in good visual acuity and graft clarity.Keywords: Descemet’s stripping endothelial keratoplasty, DSAEK, glaucoma, ocular hypertension

Purpose:The implantation of intracorneal ring segments represents an effective and safe therapeutic option for visual improvement in patients with keratoconus. The presence of corneal opacities is considered an exclusion criterion for this operation.Methods:This is a retrospective cohort study of six eyes of six keratoconus patients at Queen Victoria Hospital, East Grinstead, UK, between January 2012 and December 2016. Femtosecond laser-assisted intracorneal ring segment implantation was performed in six eyes with apical corneal haze. Preoperative and postoperative visual acuity, keratometry readings, as well as corneal pachymetry were compared at 6-month follow-up.Results:Uncorrected visual acuity (UCVA) [LogMAR] improved significantly from median 1.05 [95% confidence interval (CI): 0.83–0.13] preoperatively to 0.9 (95% CI: 0.63–1.00) at 6 months postoperatively ( p = 0.03). Corrected visual acuity (CDVA) also improved significantly from median 0.75 (95% CI: 0.43–1.00) preoperatively to 0.4 (95% CI: 0.23–0.50) at 6 months postoperatively ( p = 0.03). Keratometric readings, K-max (diopters) and K-mean (diopters), decreased significantly from 54.5 and 47.85 preoperatively to 53.45 and 46.42 postoperatively, respectively ( p = 0.03). Corneal pachymetry showed no significant changes postoperatively.Conclusion:The results of this study show that the presence of apical haze should not exclude the implantation of intracorneal ring segments in patients with keratoconus.

Purpose: To report the visual and refractive outcomes of sequential intracorneal ring segment (ICRS) and toric phakic intraocular lens (IOL) insertion for visual rehabilitation in keratoconus. Methods: A retrospective interventional cohort study was performed through the Corneoplastics unit and Eye Bank, Queen Victoria Hospital, East Grinstead, United Kingdom. Results: 14 eyes of 12 patients had sequential ICRS and phakic IOL implantation for visual rehabilitation of keratoconus between June 2014 and February 2018. After at least 6 months follow-up, the number of eyes with an uncorrected distance visual acuity (UDVA) of 20/40 UDVA or better increased from zero (0%) to 10 (71%). 12 (85.7%) eyes achieved a post-operative UDVA equal to or better than the pre-operative corrected distance visual acuity (CDVA). The number percentage of eyes with a CDVA of 20/40 or better increased from 3 (31%) to 14 (100%). The mean final spherical equivalent improved from −4.07 to −0.17 ( p ⩽ 0.001). The mean refractive astigmatism magnitude improved from 4.76D to 1.23D ( p = 0.002). Seven (50%) eyes had 1.0D or less of refractive astigmatism post-operatively. Conclusion: In this cohort of eyes with keratoconus, sequential ICRS and phakic IOL implantation resulted in excellent visual and refractive outcomes after at least 6 months.

Summary Objectives To assess for functional improvement in outcomes following supermicrosurgical restoration across a cohort of patients with a spectrum of trigeminal nerve disorders. Patients & methods In a retrospective case series over three years (2016–18), twenty patients were included in a cohort of trigeminal nerve palsy patients. Eleven patients with corneal anaesthesia underwent corneal neurotisation procedures and were followed up using Cochet-Bonnet aesthesiometry. Six patients with sensory trigeminal nerve injuries had direct nerve coaptation and neuroma excision. Three patients with trigeminal motor nerve palsies were followed up with photography for contour improvement. Results Regarding corneal neurotisation, there was evidence of significant improvement in protective corneal sensation and also blinking frequency. Regarding facial sensory disturbances, all patients had full resolution of painful trigeminal neuroma symptoms. In two cases of iatrogenic trigeminal motor palsies with contour defects, adipo-fascial variants of the superficial circumflex iliac artery (SCIP) free flap achieved excellent restoration of facial contour in lieu of facial lipofilling. In another case of a necrotising infection of the head and neck with loss of all masticatory muscles, a free functional muscle using a chimaeric vastus lateralis-ALT flap was used to restore masticatory and facial movement in a single stage procedure. Conclusion Using combinations and permutations of current surgical techniques, it is possible to successfully restore both form and function for patients with sensory as well as motor trigeminal nerve palsies. This sets a precedent for the expansion of cranial nerve surgery as an evolving sub-speciality.

Corneal neurotisation describes surgical restoration of nerve growth into the cornea to restore corneal sensation and trophic function. It represents an exciting and effective emerging treatment for neurotrophic keratopathy. Techniques described to date involve either direct nerve transfer or an interpositional nerve graft coapted to a healthy donor nerve. We review the experience to date with particular emphasis on a detailed review of techniques, outcomes and current thoughts.

PURPOSE: To investigate the potential impact of cone eccentricity on visual outcomes after Keraring (Mediphacos, Belo Horizonte, Brazil) implantation for keratoconus. METHODS: Nineteen eyes from 19 patients with keratoconus who underwent femtosecond laser–assisted Keraring implantation for keratoconus were included in this retrospective study. Uncorrected visual acuity (UDVA), corrected visual acuity (CDVA), keratometric readings, central corneal thickness, maximum keratometric distance from corneal apex (DKmax), corneal thinnest point from corneal apex (DTh), and coma were evaluated preoperatively and 6 months after the Keraring implantation. DKmax and DTh were used as metrics reflecting the eccentricity of the cone. RESULTS: UDVA, CDVA, keratometric readings, and coma improved at 6 months postoperatively. However, there was no correlation between DKmax or DTh and visual outcomes at 6 months postoperatively. CONCLUSIONS: The data did not show any impact of the cone eccentricity on visual outcomes after Keraring implantation for keratoconus at 6 months postoperatively. [ J Refract Surg. 2018;34(3):196–200.]

Purpose: To report the visual, refractive and tomographic outcomes following the implantation of intrastromal corneal ring segments (ICRS) (Ferrara rings, AJL Ophthalmics, Miñano, Spain) in eyes with a history of keratoconus and corneal cross-linking using the Ferrara ring nomogram. Methods: Retrospective, interventional case series performed at the Corneoplastics Unit, Queen Victoria Hospital, East Grinstead, United Kingdom. Results: 21 eyes of 19 patients with a history of keratoconus and prior corneal collagen cross-linking had Ferrara Intrastromal Corneal Ring Segments implanted between December 2015 and October 2017. The number, thickness and length of ring segments was chosen based on the Ferrara ring company nomogram. Mean uncorrected visual acuity (UDVA) improved from 0.88 to 0.52 logMAR (p &lt, 0.001). Mean corrected visual acuity (CDVA) improved from 0.47 to 0.36 logMAR (p = 0.046). The percentage of eyes achieving 20/40 UDVA and CDVA increased from 5% to 38% and from 38% to 67%, respectively. Of the eyes, 52.3% gained at least two lines of CDVA. The spherical equivalent improved from −7.51D to −3.76D (p &lt, 0.001) and the refractive astigmatism magnitude improved from 5.14D to 2.76D (p = 0.004). There were significant improvements in the corneal tomography with mean keratometry (KM) improving from 50.40D (3.53) to 48.24D (3.00) (p = 0.01) and keratometric astigmatism magnitude improving from 5.14D (2.91) to 2.76D (1.67) (p = 0.004). Conclusion: Insertion of Ferrara rings in keratoconic eyes with a history of prior cross-linking using the company nomogram results in significant improvements in visual, refractive and tomographic outcomes.

Background Intracorneal ring segment implantation is an effective and safe method of visual improvement in patients with keratoconus. The aim of our study was to evaluate the long-term clinical outcomes after Keraring implantation for keratoconus in patients older than 40 years. Methods Eleven eyes from 11 patients with keratoconus who underwent femtosecond laser-assisted Keraring implantation for keratoconus were included in this retrospective study. The uncorrected visual acuity (UCVA), corrected visual acuity, keratometric readings, central corneal thickness and thinnest corneal pachymetry were evaluated preoperatively and 6 months after the Keraring implantation. Results UCVA, BCVA and keratometric readings improved at 6 months postoperatively. Conclusion Our data showed significant keratometric amelioration and visual improvement after Keraring implantation for keratoconus in patients older than 40 years at 6 months postoperatively.

Zusammenfassung Hintergrund Ziel der Studie war es, die klinischen Ergebnisse nach Keraring-Implantation bei Patienten mit Keratokonus mit sehr dünnen Hornhäuten zu evaluieren. Patienten und Methoden Zehn Augen von 10 Keratokonuspatienten, bei denen eine femtosekundenlaserassistierte Ringimplantation durchgeführt worden war, wurden in diese retrospektive Studie eingeschlossen. Der unkorrigierte Visus, der korrigierte Visus, die Keratometriewerte, die zentrale Hornhautdicke und die dünnste Hornhautstelle wurden präoperativ und 6 Monate nach Keraring-Implantation ausgewertet. Ergebnisse Der unkorrigierte Visus, der korrigierte Visus und die Keratometriewerte verbesserten sich 6 Monate nach der Implantation. Schlussfolgerung Unsere Daten zeigen eine deutliche Verbesserung der Keratometriewerte und der Sehschärfe 6 Monate nach Keraring-Implantation bei Patienten mit Keratokonus und dünner Hornhaut.

Background To investigate response of dissolving collagen contact lenses as an alternative for bandage contact lenses, for the post-interventional care of epithelial defects after corneal cross-linking (CXL) treatment for keratoconus. Patients and methods Follow-up visits were performed at day 1, 4 and 1 month after the intervention. We reviewed notes for re-epithelialization, comfort/pain and any untoward effects of Collagen SOFT SHIELD (R). Assessment included visual acuity (VA), refraction (SE); corneal haze, epithelial erosion and pain status were assessed subjectively on a 4-point scale, from 0 (none) to 3 (severe). Results Thirty consecutive CXL patients with collagen shield application after CXL were included. Mean age was 28 years (range from 16 to 51 years old). Pre-CXL VA was 0.7 logMAR IQR 0.4-1.0; post-CXL VA at day 4 and month 1 was 0.6 logMAR IQR 0.4-0.9. Post-operative mean SE was 5.5D +/- 4.1D. In all patients, the Collagen SOFT SHIELD (R) was completely dissolved at the 4-day follow-up visit. In most cases, epithelial defect was closed at day 4, on average 0.8 +/- 0.5 days post-intervention; all epithelial defects were closed by month 1. Haze was minimal (mean haze score 1.4 +/- 0.7 at day 4 and 1.0 +/- 0.6 at 1 month). No adverse effects such as infection were observed. Conclusions This study indicates that Oasis Collagen SOFT SHIELD (R) is valuable and safe alternative to standard bandage contact lens for the treatment of epithelial defects. This outcome may be of particular interest in patients where the contact lens removal is likely to be problematic.

To assess the effect of cyclosporine-A (CsA) 0.05% ophthalmic emulsion on corneal sensation and ocular surface problems following cataract surgery.Prospective, randomized, double masked clinical trial.Consecutive case series of patients attending for bilateral cataract surgery. Subject's eyes were randomized to receive either topical CsA or carboxymethylcellulose 0.5% (CMC) eye drops twice daily for one month following routine cataract surgery. Subjective and objective assessments were performed pre-operatively, one week, and one month after surgery. Primary safety parameters included best spectacle-corrected visual acuity and incidence of adverse events. Objective assessments included tests of tear film (osmolarity, tear break-up time, and Schirmer's type-I test), ocular surface staining, corneal sensitivity and a subjective assessment: ocular surface disease index (OSDI) questionnaire.30 subjects (60 eyes) were recruited. At one month following cataract surgery, osmolarity, ocular surface staining, TBUT, Schirmer's results showed a greater improvement after CsA drops compared to CMC and this was statistically significant for all measures (p0.05). All corneal sensation measurements were reduced after one week and one month. Eyes receiving CsA had higher recovery of corneal sensation at both time points post operatively and this was statistically significant at one month. OSDI questionnaire results did not show a statistically significant difference between the two eyes.CsA is effective and safe in the management of ocular surface problems after cataract surgery and allows faster recovery of corneal sensation. This recovery of sensation may be relevant to the improvement in ocular surface problems in all patients.

The aim of our study was to evaluate the clinical outcomes after Keraring implantation for keratoconus in patients with thin corneas.Ten eyes from 10 patients with keratoconus, who underwent femtosecond laser-assisted Keraring implantation for keratoconus, were included in this retrospective study. Uncorrected visual acuity (UCVA), corrected visual acuity (CDVA), keratometric readings, central corneal thickness and thinnest corneal pachymetry have been evaluated preoperatively and 6 months after the Keraring implantation.UCVA, BCVA and keratometric readings improved at 6 months postoperatively.Our data showed significant keratometric amelioration and visual improvement after Keraring implantation for keratoconus in patients with thin corneas at 6 months postoperatively.Ziel der Studie war es, die klinischen Ergebnisse nach Keraring-Implantation bei Patienten mit Keratokonus mit sehr dünnen Hornhäuten zu evaluieren.Zehn Augen von 10 Keratokonuspatienten, bei denen eine femtosekundenlaserassistierte Ringimplantation durchgeführt worden war, wurden in diese retrospektive Studie eingeschlossen. Der unkorrigierte Visus, der korrigierte Visus, die Keratometriewerte, die zentrale Hornhautdicke und die dünnste Hornhautstelle wurden präoperativ und 6 Monate nach Keraring-Implantation ausgewertet.Der unkorrigierte Visus, der korrigierte Visus und die Keratometriewerte verbesserten sich 6 Monate nach der Implantation.Unsere Daten zeigen eine deutliche Verbesserung der Keratometriewerte und der Sehschärfe 6 Monate nach Keraring-Implantation bei Patienten mit Keratokonus und dünner Hornhaut.

To investigate response of dissolving collagen contact lenses as an alternative for bandage contact lenses, for the post-interventional care of epithelial defects after corneal cross-linking (CXL) treatment for keratoconus.Follow-up visits were performed at day 1, 4 and 1 month after the intervention. We reviewed notes for re-epithelialization, comfort/pain and any untoward effects of Collagen SOFT SHIELDThirty consecutive CXL patients with collagen shield application after CXL were included. Mean age was 28 years (range from 16 to 51 years old). Pre-CXL VA was 0.7 logMAR IQR 0.4-1.0; post-CXL VA at day 4 and month 1 was 0.6 logMAR IQR 0.4-0.9. Post-operative mean SE was 5.5D ± 4.1D. In all patients, the Collagen SOFT SHIELDThis study indicates that Oasis Collagen SOFT SHIELD