Recommendations for rosacea diagnosis, classification and management: update from the global ROSacea COnsensus 2019 panel.

BACKGROUND: A transition from a subtyping to a phenotyping approach in rosacea is underway, allowing individual patient management according to presenting features instead of categorization by predefined subtypes. The ROSacea COnsensus (ROSCO) 2017 recommendations further support this transition and align with guidance from other working groups. OBJECTIVES: To update and extend previous global ROSCO recommendations in line with the latest research and continue supporting uptake of the phenotype approach in rosacea through clinical tool development. METHODS: Nineteen dermatologists and two ophthalmologists used a modified Delphi approach to reach consensus on statements pertaining to critical aspects of rosacea diagnosis, classification and management. Voting was electronic and blinded. RESULTS: Delphi statements on which the panel achieved consensus of ≥ 75% voting 'Agree' or 'Strongly agree' are presented. The panel recommends discussing disease burden with patients during consultations, using four questions to assist conversations. The primary treatment objective should be achievement of complete clearance, owing to previously established clinical benefits for patients. Cutaneous and ocular features are defined. Treatments have been reassessed in line with recent evidence and the prior treatment algorithm updated. Combination therapy is recommended to benefit patients with multiple features. Ongoing monitoring and dialogue should take place between physician and patients, covering defined factors to maximize outcomes. A prototype clinical tool (Rosacea Tracker) and patient case studies have been developed from consensus statements. CONCLUSIONS: The current survey updates previous recommendations as a basis for local guideline development and provides clinical tools to facilitate a phenotype approach in practice and improve rosacea patient management. What's already known about this topic? A transition to a phenotype approach in rosacea is underway and is being recommended by multiple working groups. New research has become available since the previous ROSCO consensus, necessitating an update and extension of recommendations. What does this study add? We offer updated global recommendations for clinical practice that account for recent research, to continue supporting the transition to a phenotype approach in rosacea. We present prototype clinical tools to facilitate use of the phenotype approach in practice and improve management of patients with rosacea.

[The IC3D classification of the corneal dystrophies]. / IC3D-Klassifikation von Hornhautdystrophien.

BACKGROUND: The recent availability of genetic analyses has demonstrated the shortcomings of the current phenotypic method of corneal dystrophy classification. Abnormalities in different genes can cause a single phenotype, whereas different defects in a single gene can cause different phenotypes. Some disorders termed corneal dystrophies do not appear to have a genetic basis. PURPOSE: The purpose of this study was to develop a new classification system for corneal dystrophies, integrating up-to-date information on phenotypic description, pathologic examination, and genetic analysis. METHODS: The International Committee for Classification of Corneal Dystrophies (IC3D) was created to devise a current and accurate nomenclature. RESULTS: This anatomic classification continues to organize dystrophies according to the level chiefly affected. Each dystrophy has a template summarizing genetic, clinical, and pathologic information. A category number from 1 through 4 is assigned, reflecting the level of evidence supporting the existence of a given dystrophy. The most defined dystrophies belong to category 1 (a well-defined corneal dystrophy in which a gene has been mapped and identified and specific mutations are known) and the least defined belong to category 4 (a suspected dystrophy where the clinical and genetic evidence is not yet convincing). The nomenclature may be updated over time as new information regarding the dystrophies becomes available. CONCLUSIONS: The IC3D Classification of Corneal Dystrophies is a new classification system that incorporates many aspects of the traditional definitions of corneal dystrophies with new genetic, clinical, and pathologic information. Standardized templates provide key information that includes a level of evidence for there being a corneal dystrophy. The system is user-friendly and upgradeable and can be retrieved on the website www.corneasociety.org/ic3d .

Twenty years of acanthamoeba keratitis.

PURPOSE: We described the rate of Acanthamoeba keratitis (AK) in a referral eye center in São Paulo, Brazil, through a retrospective review of clinical and laboratorial records of patients over 2 decades. METHODS: From 1987 to 2006, a total of 581 requests for amoebic laboratory workup in cases of infectious keratitis were investigated. Statistical analyses were applied to analyze a tendency of AK cases. RESULTS: Acanthamoeba species were cultured from corneal scrapings of 185 patients, 5 of them with bilateral infection. Eighty-three percent of those patients were related with contact lens wear. CONCLUSIONS: The results suggested that patients with AK have persisted and increased over time at our ophthalmology center. Contact lenses showed to be a potential risk factor. Amoebic corneal infection can be considered as a new but well-established disease in Brazilian ophthalmology and visual sciences.

Economical LED based, real-time, in vivo imaging of murine corneal wound healing.

An optimal system for monitoring in vivo corneal wound healing is inexpensive, has utility for wounding and imaging, and is able to provide previews before photography. We outline such an imaging system that takes advantage of a consumer digital camera and an LED-based light source for fluorescein excitation. Using FVB/NJ mice, 2mm diameter, circular, axial corneal epithelial defects were created using a crescent blade. The corneal wounds were imaged every four hours until healed using a Nikon Coolpix 5400 camera attached to a Nikon SMZ-10A stereomicroscope, using the illumination from a 16 LED 464nm flashlight. The wound area was calculated, and the linear regressions of the linear phase of wound healing were compared using the F-test. The slopes of the linear regressions for the 6 trials of 4 mice/trial had an average of -52.95microm/h (SEM=0.55microm/h) and were statistically equivalent (p>0.05). The mean of the R(2) values for the linear regressions was 0.9546 (SEM=0.0121). The equivalent linear regressions and R(2)>0.90 suggest that the imaging system could precisely monitor the wound healing of multiple trials and of animals within each trial, respectively. Using a consumer digital camera and LED-based illumination, we have established a system that is economical, is used in both wounding and imaging, is operated by a single person, and is able to provide real-time previews to monitor corneal wound healing precisely.

The in vitro activity of selected defensins against an isolate of Pseudomonas in the presence of human tears.

BACKGROUND/AIMS: Pseudomonas aeruginosa is a major cause of severe bacterial keratitis and remains a difficult clinical entity to treat successfully with the current arsenal of antimicrobial agents. Defensins are small cationic peptides with broad in vitro antimicrobial activity and are potential ocular therapeutic agents. The authors characterised the in vitro activity of defensins NP-1 and NP-3a against P aeruginosa in the presence of human tears. METHODS: A clinical Pseudomonas isolate was grown to mid-log phase, and 1 x 10(6 )colony forming units were exposed to the peptides (200 microg/ml) for up to 2 hours in the presence of varying concentrations (10-70%) of human tears. RESULTS: For both peptides in the presence of 10% tears, >3 log units of killing was achieved within 30 minutes. In 70% tears, NP-1 produced >1 log unit of killing at 2 hours, indicating that, although reduced, its activity remained significant. In 20% tears, NP-3a demonstrated 2 log units of killing at 2 hours; however, the antimicrobial activity of this defensin was completely inhibited in the presence of 70% tears. CONCLUSION: These in vitro data suggest that while the microbicidal activity of some defensins may be diminished at the ocular surface in vivo, significant activity is still possible with certain peptides.

Aerobic bacterial conjunctival flora in diabetic patients.

OBJECTIVE: To study the aerobic conjunctival flora of diabetic patients and its relation to the presence and level of diabetic retinopathy and the duration of the disease. METHODS: One hundred three patients from the diabetic retinopathy screening program of the Federal University of São Paulo with no evidence of ocular surface disease were included. The diabetic patient cohort was compared with 60 nondiabetic subjects. All patients underwent slit-lamp evaluation, conjunctival scrapings, and indirect ophthalmoscopy. RESULTS: The frequency of positive conjunctival cultures was significantly higher in the diabetic group (94.18%) than in the nondiabetic group (73.33%). Among diabetic patients, a significantly higher frequency of positive cultures was detected in those with diabetic retinopathy than in those without retinopathy. Neither the duration of the diabetes nor the hypoglycemic therapy correlated with the culture results. Coagulase-negative Staphylococcus was the most common microorganism isolated, and its identification was more frequent in patients with retinopathy than in those without diabetic retinopathy. CONCLUSION: Diabetic patients have a significantly higher number of positive conjunctival cultures. The presence of diabetic retinopathy was correlated with an increase in positive cultures and a higher proportion of coagulase-negative Staphylococcus.

Intraocular lens power calculation after laser in situ keratomileusis for myopia and hyperopia: a standardized approach.

PURPOSE: (1) To determine the effect of myopic and hyperopic laser in situ keratomileusis (LASIK) on calculation of intraocular lens (IOL) power. (2) To determine a standard way to approach the IOL power determination after LASIK, and (3) To compare different suggested methods. METHODS: Biometric analysis and theoretical calculation of IOL powers for eyes undergoing LASIK for myopia and hyperopia were performed. RESULTS: Manual keratometry after LASIK for myopia resulted in underestimation of IOL power. Manual keratometry after hyperopic LASIK resulted in overestimation of IOL power. The amount of error was directly related to the amount of correction by LASIK. CONCLUSION: The pre-LASIK refraction can be used theoretically to determine an accurate IOL power.

Anterior keratoconus associated with unilateral cornea guttata.

PURPOSE: To describe a 30-year-old man with bilateral but asymmetric anterior keratoconus and unilateral cornea guttata in the eye with more advanced keratoconus. METHOD: Case report. RESULTS: The patient's keratoconus was diagnosed three or four years earlier. The keratoconus was confirmed by slit-lamp examination, keratometry, and computer-assisted topographic analysis. Cornea guttata were confirmed by clinical examination and specular microscopy. CONCLUSION: This is a rare case of unilateral cornea guttata associated with asymmetric keratoconus, showing severe guttate change only in the eye with more advanced keratoconus.

Making sense of refractive surgery in 2001: why, when, for whom, and by whom?

Surgical alteration of the focusing or refractive properties of the eye has been performed on millions of patients. An array of procedures to correct myopia, hyperopia, astigmatism, and presbyopia have been introduced over the past 25 years with varying degrees of success. Improved technology has increased patient and physician satisfaction and enthusiasm. Currently available surgical procedures can be categorized as incisional, surface-altering, lamellar, and intraocular. The choice of procedure depends on individual patient indications and contraindications based on results of ocular examinations, eg, corneal pachymetry to measure corneal thickness, keratometry to measure the corneal curvature, basal tear secretory rate, and dark-adapted pupil size. The postoperative uncorrected visual acuity depends, in large part, on the quality of the preoperative evaluation and refraction. Before scheduling a patient for surgery, the ophthalmologist must ensure that the patient understands the potential risks of the procedure and has realistic expectations for the postoperative level and quality of uncorrected visual acuity. Postoperative complications include corneal flap displacement, undercorrection and overcorrection, and epithelial ingrowth under the corneal flap and inflammatory keratitis. Postoperative dry eye, infection, and inflammation are usually treated medically. Ongoing technological innovations to customize the surgical approach to an individual patient's eye continue to improve outcomes.

Peripheral nonulcerative keratitis as a presenting sign of microscopic polyangiitis.

PURPOSE: To report a 16-year-old woman who had peripheral keratitis as a presenting sign of microscopic polyangiitis (MPA), which rapidly progressed to acute renal failure. METHOD: Case report. RESULTS: The patient's vasculitis was diagnosed by renal biopsy, which was evaluated with histologic, immunofluorescence, and electron microscopy. The diagnosis was confirmed by laboratory study, which showed a positive antimyeloperoxidase antibody. CONCLUSION: MPA may rarely present with ocular findings and should be considered in the differential diagnosis when a patient has peripheral keratitis.

Surface keratopathy after penetrating keratoplasty.

PURPOSE: To determine the type and prevalence of epithelial abnormalities in the intermediate postoperative period after penetrating keratoplasty and to define the donor and recipient variables that influence the status of the graft epithelium. DESIGN: Prospective cohort study. METHODS: We prospectively followed the clinical course of 80 patients after penetrating keratoplasty. We monitored the status of the corneal epithelium for 3 months after surgery using slit-lamp biomicroscopy and fluorescein staining of the epithelium. Donor characteristics, recipient preoperative and postoperative variables, and postoperative medications were recorded. Epithelial abnormalities were analyzed against these variables by using univariate and combined statistical models to determine the impact of each variable on postoperative epithelial pathology. Main outcome measures included punctate keratopathy, macro-epithelial defects, hurricane keratopathy, rim defects, and filamentary keratopathy. RESULTS: Sixty-three percent of all patient visits demonstrated punctate epithelial keratopathy (PEK). Hurricane keratopathy (51%) and filamentary keratopathy (14%) constituted the next most commonly observed abnormalities. Older recipient age and the use of topical antibiotics were associated with a higher prevalence of punctate epithelial keratopathy. The odds ratio (OR) for a 1-year increase in age is 1.0276 (95% CI, 1.1013-1.0442), and the OR for using topical antibiotics is 6.9028 (95% CI, 3.1506-15.1239). Use of topical ofloxacin and increased time after surgery were associated with lower prevalence of punctate keratopathy; ORs were 0.9806 (95% CI, 0.9736-0.9876) and 0.3662 (95% CI, 0.1688-0.7943), respectively. Decreased corneal sensation and the presence of anterior blepharitis preoperatively were associated with an increase in hurricane keratopathy; ORs were 8.8265 (CI, 2.3837-32.6835) and 3.2815 (CI, 1.7388-6.1931), respectively. Total storage time for the donor material was also associated with an increased prevalence of hurricane keratopathy (OR, 1.0316; CI, 1.0052-1.0220). Patients with rim defects and macro-epithelial defects were more likely to have antibiotic and topical lubrication prescribed. No specific variable was found to have a significant association with filamentary keratopathy, except possibly for death-to-preservation time, which had a P value of .0587. CONCLUSIONS: Surface keratopathy is one of the most common complications of keratoplasty. Our study demonstrates that older age, preoperative lid disease, and decreased preoperative corneal sensation appear to increase the probability of clinically significant epithelial surface abnormalities after keratoplasty. Recognition of these risk factors in advance of surgery will alert the surgeon to the need for appropriate management.

Evaluating pterygium severity: a survey of corneal specialists.

PURPOSE: Accurate and reliable evaluation techniques are essential for clinical and epidemiologic studies. This survey of corneal specialists was designed to lay a foundation for the further development of methods for evaluating and staging pterygium. METHODS: In a self-administered, mailed questionnaire, 213 corneal specialists rated the importance of nine symptoms, nine signs, and nine clinical tests for the severity of primary pterygium. Severity was defined as the present need for surgical intervention. RESULTS: The most important factors for determining primary pterygium severity were the extent of encroachment onto the cornea, decreased visual acuity, restricted ocular motility, and increased rate of growth. Many patient symptoms were rated as moderately to highly important. The questionnaire was shown to have good response reliability by test-retest comparisons. Cronbach's alpha was 0.89, which indicates very good internal consistency reliability. CONCLUSION: The survey identifies the priorities of experts in determining the severity of pterygium. More precise and clearly defined evaluation methods will enhance future clinical and epidemiologic studies of pterygium. The ranked list of pterygium signs, symptoms, and tests can serve as a guide for developing pterygium evaluation methods in the future. There is a need for a method that accurately and precisely quantifies the distance of pterygium encroachment onto the cornea and the pterygium progression rate. Furthermore, there is a need for an assessment of patient symptoms.

Penetrating keratoplasty for keratoconus.

PURPOSE: We performed a retrospective study of patients with keratoconus who underwent penetrating keratoplasty at the University of California, Davis, during the years 1983-1996 to analyze subsequent visual acuity and the need for optical correction. METHODS: We reviewed 123 eyes of 94 patients and collected data including best corrected visual acuity (BCVA) and uncorrected visual acuity (UCVA), type of correction (contact lens vs. spectacles), incidence of rejection, and other complications. Data were obtained at 12 and 18 months postoperatively. RESULTS: There was a significant improvement of the BCVA between 12 and 18 months (p < 0.05) and no significant improvement in UCVA between at the same times (p = 0.222). At 12 months postoperatively, 84%, and at 18 months, 87% of patients achieved 20/40 or better BCVA. At 18 months, 47% of eyes were fit with contact lenses, and 30%, with spectacles. Mean spherical refraction was -4.13 D +/- 4.41 standard deviation (SD) at 12 months and -4.09 D +/- 3.86 SD at 18 months, whereas mean cylinder was 2.52 D +/- 2.45 SD and 2.67 D +/- 2.04 SD, respectively. Of the eyes, 17.9% had at least one graft rejection, although rejection episodes did not significantly influence the incidence of 20/40 vision (p = 0.084). Combined nonrejection complications did not significantly influence incidence of 20/40 or better vision at 18 months (p > 0.10). CONCLUSION: This study reaffirms that the results for keratoplasty in keratoconus are very positive and emphasizes that ophthalmologists should counsel patients about the likelihood of the need for spectacle or contact lens correction. Our data demonstrate that the majority of patients require optical correction for functional visual acuity after keratoplasty.

Technique for harvesting keratolimbal allografts from corneoscleral buttons.

PURPOSE: To report a method for obtaining thin keratolimbal lenticules from cadaveric corneoscleral buttons for corneal epithelial stem cell allografts. METHOD: A standard silicone orbital sizing sphere and three 25-gauge needles were employed to fix the corneoscleral button to facilitate excision of keratolimbal lenticules. RESULT: Limbal stem cells in the form of keratolimbal lenticules were obtained without difficulty. CONCLUSION: With this technique, thin keratolimbal lenticules of good quality can be obtained efficiently, inexpensively, and without specialized instruments.

Single culture media in infectious keratitis.

PURPOSE: To evaluate the usefulness of the various culture media used in the traditional workup in infectious keratitis. METHODS: Microbiology data sheets from all corneal cultures performed at the University of California Davis Medical Center over a 1-year period were reviewed retrospectively. RESULTS: Bacterial cultures were sent in 76 cases. In 19 cases, culture specimens from ulcers were plated onto blood, chocolate, and inhibitory mold agar and were inoculated into an anaerobic medium. In 58 cases, blood and chocolate agar were sent. In 70% of cases, blood and chocolate agar provided identical information. Inhibitory mold agar was positive twice in 39 plates sent. A fungal pathogen had been identified on chocolate agar plates sent for these cases. CONCLUSION: In the evaluation of infectious keratitis, plating onto chocolate agar or blood agar alone is a reasonable alternative to sending multiple cultures.