Management of Ocular Surface Inflammation with Persistent Epithelial Defects Using a Sutureless Human Amniotic Membrane Dehydrated Matrix: A Prospective Study Utilizing a Digital Ocular Surface Assessment Tool.

Purpose: To report the outcomes of using a sutureless human amniotic membrane dehydrated matrix (HAMDM) in the management of a range of ocular surface conditions utilizing a digital ocular surface disease assessment tool. Methods: Two UK NHS Trusts - Queen Victoria Hospital Foundation Trust (East Grinstead and Maidstone) and Tunbridge Wells Trust (Kent) - prospectively treated patients with ocular surface disease with sutureless HAMDM. The patient cohort was assessed for resolution of epithelial defects, ocular surface inflammation, and best-corrected visual acuity pre- and posttreatment. Measurements of ocular surface inflammation and epithelial defect size were assessed using AOS digital imaging software, a validated tool for objective grading of bulbar conjunctival redness and measurement of corneal epithelial defects. Results: A total of 47 applications of sutureless HAMDM on 46 eyes of 46 patients (25 male, 21 female, age 9-94 years) were assessed across various etiologies for an average of 24.0±14.1 days. Patients with limbal stem-cell deficiency (n=17), persistent epithelial defects (n=16), neurotrophic corneal disease (n=7), filamentary keratitis (n=2), corneal erosion (n=1), corneal thinning (n=1), ocular surface inflammation (n=1), and traumatic corneal laceration (n=1) were included in the study. Across all patents, 63% of eyes showed complete healing of epithelial defects and 32.6% of eyes showed partial resolution. The average rate of healing (wound closure) was 0.36 mm2 per day across the overall patient cohort, and the rate of healing in cases with complete resolution of epithelial defects was 0.41 mm2 per day. Inflammation across all four quadrants of the ocular surface remained stable. Visual acuity across the patient cohort remained stable (61%) and improved in 26% of patients (0.06±0.51 logMAR). Conclusion: Sutureless HAMDM application can be accomplished in just a few minutes and effectively treat a range of ocular surface disease in a clinical, nonsurgical setting. The AOS imaging software offered a quantitative methodology for measuring epithelial defect size and inflammation state.

One-year visual outcome of secondary piggyback pinhole device implantation in pseudophakic eyes with irregular corneal astigmatism and iris trauma.

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.

Clinical Characteristics and Outcomes of Fungal Keratitis in the United Kingdom 2011-2020: A 10-Year Study.

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 (>3 mm), and poor presenting CDVA (<1.0 logMAR) as significant negative predictive factors for poor visual outcome (CDVA of <1.0 logMAR) and poor corneal healing (>60 days of healing time or occurrence of corneal perforation requiring emergency keratoplasty; all p < 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.

Ferrara Rings for Visual Rehabilitation in Eyes with Keratoconus and Previous Cross-Linking Using the Ferrara Ring Nomogram.

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 < 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 < 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.

Clinical outcomes after intracorneal ring segment implantation for keratoconus management in corneas with mild apical haze.

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.

Management of Persistent Corneal Epithelial Defects with Human Amniotic Membrane-derived Dry Matrix.

OBJECTIVE: 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.

Incidence and Risk Factors of Ocular Hypertension/Glaucoma After Descemet Stripping Automated Endothelial Keratoplasty.

PURPOSE: 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.

Tear film parameters before and after intracorneal ring segment implantation in keratoconic eyes.

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 < 0.64, and p < 0.91, respectively). The NITUBT was significantly lower after surgery (p = 0.04). 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.

First experience with Oasis Collagen SOFT SHIELD® for epithelial defect after corneal cross-linking.

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®. 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® 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® 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.

[Clinical Outcomes after Keraring Implantation for Keratoconus Management in Thin Corneas]. / Klinische Ergebnisse nach Keraring-Implantation zur Behandlung von Keratokonuspatienten mit sehr dünnen Hornhäuten.

BACKGROUND: The aim of our study was to evaluate the clinical outcomes after Keraring implantation for keratoconus in patients with thin corneas. PATIENTS AND METHODS: 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. RESULTS: UCVA, BCVA and keratometric readings improved at 6 months postoperatively. CONCLUSIONS: Our data showed significant keratometric amelioration and visual improvement after Keraring implantation for keratoconus in patients with thin corneas at 6 months postoperatively.

Refractive Nightmares Revisited: Calcification of a Multifocal Intraocular Lens.

BACKGROUND/AIM: Cataract is the leading cause of reversible blindness and visual impairment worldwide. Although cataract surgery using phacoemulsification and intraocular lens (IOL) implantation is one of the commonest surgical procedures, IOL opacification remains a potential complication that can affect the visual outcome of the operation. CASE REPORT: A 50-year-old female patient presented to our clinic complaining of glare and blurry vision in her right eye over the previous 6 weeks. She had undergone bilateral refractive lens exchange elsewhere 9 months earlier. Her unaided distance visual acuity was 8/10 in the right eye and 10/10 in the left. On slit-lamp examination, we observed the presence of in-the-bag, multifocal, hydrophobic acrylic IOLs bilaterally. Specifically, calcified deposits within the substance of the IOL were observed. CONCLUSION: To our knowledge, this is the first case of spontaneous calcification of a hydrophobic multifocal IOL and all cataract/refractive surgeons should be aware of this rare complication.

Effect of Conus Eccentricity on Visual Outcomes After Intracorneal Ring Segments Implantation in Keratoconus.

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.].

Clinical Outcomes after Keraring Implantation for Keratoconus Management in Patients Older Than 40 Years: A Retrospective, Interventional, Cohort Study.

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.

Peripheral corneal relaxing incisions based on anterior keratometry from Scheimpflug tomography versus Placido topography during standard cataract surgery.

AIM: To compare the outcomes of peripheral corneal relaxing incisions (PCRIs) based on standardized nomogram using keratometry from Scheimpflug and Placido machines during standard cataract surgery and to assess the astigmatism neutralization potential of PCRIs. METHODS: In this prospective, comparative case series of eyes with keratometric astigmatism between 0.75D to 2.5D, undergoing routine cataract surgery, PCRIs were performed using standardized nomogram and keratometric data from either Scheimpflug or Placido machines. A single eye of 42 consecutive patients was recruited in each group. Data on pre- and postoperative uncorrected distance visual acuity (UDVA), corrected DVA (CDVA), keratometry and refraction were assessed at 10 weeks postoperatively. Refractive and keratometric J0 J45 vectors were also analyzed. RESULTS: Data on 41 and 39 eyes were available in each group, respectively. There was a significant reduction in keratometric astigmatism in both groups. However, between Scheimpflug and Placido groups, there was no difference in postoperative logMAR UDVA [0.15 ± 0.18 vs 0.14 ± 0.16, p = 0.82] and CDVA [0.11 ± 0.11 vs 0.09 ± 0.10, p = 0.58], postoperative spherical equivalent [-0.34D ± 0.40D vs -0.50D ± 0.43D, p = 0.11], keratometric J0 [-0.03 ± 0.39 vs 0.01 ± 0.85, p = 0.67] and J45 [-0.03 ± 0.41 vs 0.01 ± 0.86, p = 0.65] and refractive J0 [0.05 ± 0.46 vs -0.03 ± 0.92, p = 0.47)] and J45 [-0.06 ± 0.49 vs -0.03 ± 0.99, p = 0.82] vectors, reduction of keratometric astigmatism [-0.40D ± 0.55D vs -0.35D ± 1.24D, p = 0.75] and the keratometric astigmatism neutralization potential [38.56 % ± 29.71 % vs 52.66 % ± 44.06 %, p = 0.12]. - CONCLUSIONS: Although PCRIs performed using Scheimpflug or Placido keratometry reduced the keratometric astigmatism significantly during standard cataract surgery. The astigmatic neutralization potentials of PCRIs comparing these two groups were not significantly different and remain low during the early postoperative period.

Patients with Fuchs Endothelial Dystrophy and Cataract Undergoing Descemet Stripping Automated Endothelial Keratoplasty and Phacoemulsification with Intraocular Lens Implant: Staged versus Combined Procedure Outcomes.

Purpose. To compare the surgical outcomes of staged and combined phacoemulsification with intraocular lens implant (phaco+IOL) and Descemet stripping automated endothelial keratoplasty (DSAEK) in patients with Fuchs' endothelial dystrophy and cataract. Setting. Corneoplastic Unit and Eye Bank, Queen Victoria Hospital, East Grinstead, UK. Methods. Retrospective study of patients who had combined phaco+IOL and DSAEK (group 1) or phaco+IOL followed within 2 months by DSAEK (group 2). Patients who had previous eye surgery or any other ocular comorbidities were excluded. Results. There were 28 eyes in group 1 and 31 in group 2. There were no significant differences in the demographics and corneal tissue characteristics of the two groups. The endothelial disc dislocation and rebubbling rate within 1 week in group 1 was 21.42% and in group 2 was 3.2% (P = 0.04), while the endothelial cell density at 12 months was 1510 ± 433 for group 1 and 1535 ± 482 for group 2 (P = 0.89). The mean 12-month logMAR visual acuity was 0.28 ± 0.24 for group 1 and 0.33 ± 0.15 for group 2 (P = 0.38). Conclusions. Although the combined procedure seems to be associated with a higher complication rate the final outcomes seem to be similar to both methods.