Quantum Molecular Resonance Electrotherapy for the Treatment of Pediatric Ocular Rosacea.

PURPOSE: The purpose of this study was to report the outcomes of quantum molecular resonance (QMR) electrotherapy in the management of refractory pediatric ocular rosacea. METHODS: This is a retrospective case series on 3 female pediatric patients (ages 12, 15, 14 years) with ocular rosacea. Two patients presented with corneal stromal neovascularization and punctate epithelial erosions while 1 patient presented with corneal scarring and paracentral stromal thinning. After failing conservative management, the patients were treated with 4 consecutive QMR electrotherapy sessions with the intensity set at 5 corresponding on average to a power of 12 W, with 60 V voltage and 200 mA current. Informed consent was obtained for off-label use. Patients were assessed for changes in vision, foreign body sensation, tearing, photophobia, and redness at each visit to determine symptomatic improvement. Outcome measures include best-corrected visual acuity, use of supplemental therapies (eg topical steroids) for symptom relief, extent of corneal neovascularization via serial slitlamp photography, and corneal scar remodeling via high resolution anterior segment optical coherence tomography (OCT). RESULTS: Two of the 3 patients experienced improvement in visual acuity after QMR electrotherapy. Corneal neovascularization and scarring regressed significantly in all 3 patients. Two months post-QMR electrotherapy, corneal remodeling was evident on optical coherence tomography in 2 patients. All 3 patients were able to discontinue topical immunosuppressants and remain symptom-free at 1.5 years of follow-up. CONCLUSIONS: QMR electrotherapy is a promising alternative in the treatment of refractory ocular rosacea in childhood and puberty, and it may potentiate corneal remodeling.

Progressive Keratoconus in a Patient With Severe Pectus Excavatum and a Cartilage Oligomeric Matrix Protein Gene Mutation: A Case Report.

INTRODUCTION: Keratoconus is a progressive ocular disorder associated with numerous systemic diseases, many of which affect the musculoskeletal system. Although the etiology and pathophysiology of the disorder remain elusive, recent studies suggest a significant role of genetic predisposition in the pathogenesis of keratoconus. This case report aims to elucidate a potential genetic association in a patient presenting with keratoconus, severe pectus excavatum, generalized muscular weakness, and skeletal deformities. CASE DESCRIPTION: A 31-year-old Iranian man presented with progressively diminishing vision in both eyes over the years, eventually diagnosed with keratoconus. The patient's history and further examination indicated generalized muscular weakness, skeletal deformities, and severe pectus excavatum with cardiac and large vessel displacement. Whole-exome sequencing identified two heterozygous gene variants: one in the Cartilage Oligomeric Matrix Protein (COMP) gene and another in the Regulating Synaptic Membrane Exocytosis 1 gene. The patient's systemic and ocular symptoms, combined with the gene variants identified, suggested a connective tissue systemic disorder, potentially within the clinical spectrum of COMPopathies. CONCLUSION: This is the first documented case of bilateral progressive keratoconus associated with severe pectus excavatum, generalized musculoskeletal dystrophy, and a COMP gene mutation. It highlights the necessity of continued search into the pathogenic genes of keratoconus, particularly in cases with coexisting systemic manifestations, to further our understanding of the etiology and pathogenesis of this complex disease.

A Rare Manifestation of Discoid Lupus Erythematosus Solely in the Lower Eyelid of a Young Man.

Discoid lupus erythematosus (DLE)-associated edema and erythema on the lower eyelid as the only manifestation of the disease is a rare clinical entity. Persistent discoid lupus-related lower eyelid manifestations are challenging to diagnose, can be mistaken for blepharitis or malignancies, and often require histopathological evaluation. If left untreated, the condition can progress, among others, to conjunctival scarring or symblepharon formation. Thus, early identification and management of the disease entity is of the utmost significance. We present a rare case of a young patient with enduring, unilateral lower eyelid edema and erythema that had been managed as blepharitis for several years. No other related cutaneous involvement was detected on the eyelids, face, or body. Following a lower eyelid biopsy and histopathological assessment, the patient was diagnosed with underlying DLE. This case report reviews the previous literature, discusses a differentiation strategy from other relevant pathologies, such as blepharitis and sebaceous cell carcinoma, and highlights the implemented diagnostic procedures.

Semi-Autologous Corneal Transplantation with Simultaneous Bilateral Surgery: A Case Report.

The present report describes a case of semi-autologous corneal transplantation with bilateral surgery using two operating microscopes simultaneously. An 86-year-old man with history of six prior failed penetrating keratoplasties in his right eye presented with decreased vision. His other eye was deeply amblyopic but had a clear 30-year-old Castroviejo-square graft with an endothelial cell count of 803 cells/mm2. A semi-autologous graft was performed from the left eye to the right. Surgery was performed simultaneously on both eyes by two different surgeons using a standard ophthalmic operating microscope as well as a second ENT microscope. Upon trephination of the right failed corneal graft, vitreous opacities were noted and sent for culture. The semi-autologous tissue was directly transferred from the left eye to the right without any storage in preservation media to avoid endothelial cell loss. The semi-autologous graft remained clear in the immediate postoperative period. However, the vitreous cultures grew coagulase-negative Staphylococcus. Despite all efforts, the patient eventually developed a retinal detachment and vision in the right eye decreased to light perception. Autologous penetrating keratoplasty is an option for patients with loss of corneal function in a potentially seeing eye and a clear cornea in a contralateral eye with poor visual potential due to non-corneal disease. This case is unique in that part of the autologous penetrating keratoplasty had an old square graft in the center and corneal transplant surgery was done simultaneously in both eyes. It also highlights chronic indolent endophthalmitis as a potential cause of multiple graft failures.

Systematic review of sample size calculations and reporting in randomized controlled trials in ophthalmology over a 20-year period.

PURPOSE: Randomized Controlled Trials (RCTs) are considered the gold standard for the practice of evidence-based medicine. The purpose of this study is to systematically assess the reporting of sample size calculations in ophthalmology RCTs in 5 leading journals over a 20-year period. Reviewing sample size calculations in ophthalmology RCTs will shed light on the methodological quality of RCTs and, by extension, on the validity of published results. METHODS: The MEDLINE database was searched to identify full reports of RCTs in the journals Ophthalmology, JAMA Ophthalmology, American Journal of Ophthalmology, Investigative Ophthalmology and Visual Science, and British Journal of Ophthalmology between January and December of the years 2000, 2010 and 2020. Screening identified 559 articles out of which 289 met the inclusion criteria for this systematic review. Data regarding sample size calculation reporting and trial characteristics was extracted for each trial by independent investigators. RESULTS: In 2020, 77.9% of the RCTs reported sample size calculations as compared with 37% in 2000 (p < 0.001) and 60.7% in 2010 (p = 0.012). Studies reporting all necessary parameters for sample size recalculation increased significantly from 17.2% in 2000 to 39.3% in 2010 and 43.0% in 2020 (p < 0.001). Reporting of funding was greater in 2020 (98.8%) compared with 2010 (89.3%) and 2000 (53.1%). Registration in a clinical trials database occurred more frequently in 2020 (94.2%) compared to 2000 (1.2%; p < 0.001) and 2010 (68%; p < 0.001). In 2020, 38.4% of studies reported different sample sizes in the online registry from the published article. Overall, the most studied area in 2000 was glaucoma (29.6% of RCTs), whereas in 2010 and 2020, it was retina (40.2 and 37.2% of the RCTs, respectively). The number of patients enrolled in a study and the number of eyes studied was significantly greater in 2020 compared to 2000 and 2010 (p < 0.001). CONCLUSION: Sample size calculation reporting in ophthalmology RCTs has improved significantly between the years 2000 and 2020 and is comparable to other fields in medicine. However, reporting of certain parameters remains inconsistent with current publication guidelines.

Outcomes of Combined Penetrating Keratoplasty and Limbal Stem Cell Transplantation: A Meta-Analysis on Simultaneous Versus Sequential Surgery.

PURPOSE: The objective of this study is to perform a systematic review and meta-analysis of the published studies on limbal stem cell transplantation (LSCT) combined with penetrating keratoplasty (PK) performed either simultaneously or sequentially. METHODS: An extensive search was conducted in the MEDLINE and Google Scholar databases. Prospective and retrospective trials and case series reporting on the outcomes of LSCT with PK were included. Primary outcomes were the stability of the ocular surface and the rejection and/or failure of the corneal graft. RESULTS: A total of 209 eyes from 13 studies were included in the simultaneous group and 489 eyes from 33 studies in the sequential group. Ocular surface stability was 88% [95% confidence interval (CI), 79%-96%] for sequential cases and 64% (95% CI, 43%-82%) for simultaneous cases ( P = 0.001). The graft failure rate was 15% (95% CI, 6%-26%) for sequential cases and 44% (95% CI, 31%-58%) for simultaneous cases ( P < 0.001). For cases performed sequentially, subgroup analysis revealed a stable ocular surface in 97% (95% CI, 91%-100%) of autograft cases and 63% (95% CI, 45%-80%) of allograft cases ( P < 0.001). The graft failure rate in sequential cases was 7% (95% CI, 0%-18%) for autografts and 34% (95% CI, 18%-52%) for allografts ( P < 0.001). CONCLUSIONS: Sequential LSCT followed by PK demonstrated superior results in terms of ocular surface stability and graft retention compared with simultaneous LSCT and PK. Limbal stem cells of autologous origin fare better than allogeneic ones in sequential cases.

Ab Interno Goniotomy with the Kahook Dual Blade in a Monocular Patient with Mucous Membrane Pemphigoid and Refractory Open Angle Glaucoma: A Case Report.

Purpose: To describe the case of a monocular patient with ocular mucous membrane pemphigoid (MMP) and open angle glaucoma refractory to medical treatment, who was successfully managed with ab interno goniotomy at the time of cataract surgery. Methods: A 63-year-old woman with a history of severe MMP presented with exacerbation of the disease in both eyes. Vision was 20/80 in the right eye and light perception in the left eye. Symblepharon formation, trichiasis and forniceal foreshortening were present in the right eye, while the cornea of the left eye was completely conjunctivalized. Following aggressive systemic immunosuppressive therapy with corticosteroids and cyclophosphamide, the disease was brought under control. However, the patient developed a mature cataract and high intraocular pressure (IOP) of 28 mmHg on maximal medical therapy. Due to the high risk of ocular MMP exacerbation with glaucoma filtration surgery, the decision was made to proceed with cataract extraction combined with ab interno goniotomy with the Kahook Dual Blade. Results: There were no intraoperative complications. The IOP has remained in the 12-14 mmHg range without any topical glaucoma medications over a total follow up of 3.5 years. Conclusion: Ab interno goniotomy using the Kahook Dual Blade can significantly reduce IOP and medication burden in MMP cases, where any type of conjunctival incisional surgery could induce disease flare up. In this case, it represented a safe and effective surgical procedure for ocular MMP with concomitant refractory open angle glaucoma.

Paraneoplastic Pemphigus Associated with Bilateral Corneal Perforations in Follicular Dendritic Cell Sarcoma.

PURPOSE: To describe a case of paraneoplastic pemphigus (PNP) presenting as spontaneous bilateral corneal perforations in a patient with follicular dendritic cell sarcoma. METHODS: Retrospective chart reviewResults: A 73-year-old Greek woman with a history of follicular dendritic cell sarcoma (FDCS) presented with bilateral corneal perforations and a cicatrizing conjunctivitis. Her diagnosis was consistent with PNP with corneal and conjunctival involvement after a change in her chemotherapy regimen from intravenous cyclophosphamide to gemcitabine. She was treated with a multilayered amniotic membrane in the right eye and cyanoacrylate glue in the left eye. Systemic intravenous cyclophosphamide and oral prednisone were re-started. Both perforations healed but the patient passed away soon after precluding further follow-up. CONCLUSIONS: Ocular manifestations of PNP can rarely present with spontaneous corneal perforations. This is the first case of FDCS-associated PNP with corneal involvement. Such cases should be diagnosed expediently and managed with aggressive systemic immunosuppressive therapy.

Cost-Benefit Analysis of Single versus Repeated Use of Single-Use Devices in Cataract Surgery.

PURPOSE: To estimate the net cost effect associated with the real-world practice of repeated use of designated single-use medical devices (SUDs) versus their proper single use in cataract surgery in Greece. DESIGN: A cost-benefit analysis model was constructed in the form of a decision tree. METHODS: A digital expert panel was assembled in order to estimate the probabilities of intraoperative and postoperative complications associated with single and repeated use of SUDs. Unit costs for the management of each complication were obtained from the official Greek bulletins. A Monte Carlo-type sensitivity analysis was performed to assess the robustness of the results. RESULTS: Based on the probabilities of complications attained from the expert panel, repeated use of SUDs is associated with a higher chance of complications compared to single use, which results in higher cost of complication management. Under the healthcare sector perspective, the total expected cost per cataract surgery is 1,403.98€ (1,244.20€ the initial cost of cataract surgery plus 159.78€ the cost of adverse events) in the case of single use, while for repeated use the total cost is 1,486.29€ (1,146.86€ + 339.43€, respectively) and, thus, repeated use of SUDs in cataract surgery results in 82.31€ higher expected cost per patient compared to their single use. Moreover, the societal perspective analysis indicated even higher additional costs in the case of SUD reuse (108.24€). CONCLUSION: Repeated use of SUDs in cataract surgery is not appropriate, it jeopardizes patient safety and carries a legal liability for the reuser. The present study, which is the first to attach a monetary value to the common yet questionable practice of SUD reuse, shows that it is not cost beneficial. Therefore, it is expected that the results will have implications in policy formulations to improve the delivery of cataract healthcare.

Endothelial Biopsy for the Diagnosis and Management of Culture-Negative Retrocorneal Fungal Keratitis With the Assistance of Optical Coherence Tomography Imaging.

PURPOSE: To report a case of a culture-negative deep fungal corneal infection that was diagnosed after histopathology of an anterior segment optical coherence tomography-guided endothelial biopsy. METHODS: A 22-year-old woman with history of contact lens wear and concomitant topical steroid use presented with a mid-stromal corneal infiltrate that failed to respond to oral acyclovir and topical fortified antibiotics. Although cornea stains, cultures, and confocal microscopy showed negative results, there was high clinical suspicion for fungal keratitis. After 2 months on topical natamycin, oral voriconazole, and serial intrastromal and intracameral voriconazole injections, the infiltrate enlarged and deepened. Imaging with anterior segment optical coherence tomography revealed that the infection had progressed to an endothelial plaque. RESULTS: Diagnostic endothelial biopsy was performed in the operating room. Cultures showed again negative results, whereas histopathology of the removed specimen revealed fungal elements. The postoperative edema at the site of the biopsy resolved over the course of 4 weeks, and a posterior stromal scar formed. Serial intrastromal and intracameral voriconazole injections were continued for the first postoperative month. At the 1-year and the 3-year follow-up examinations, the patient's vision was 20/20 without recurrence. CONCLUSIONS: Intraoperative scraping of the endothelial plaque and histopathologic evaluation of the specimen proved to be of utmost importance for definitive diagnosis and resolution of the culture-negative deep fungal infection in this case. This young patient's cornea was retained and vision remains excellent.

Management of Stromal Herpes Simplex Virus Keratitis With Epithelial Ulceration Using Optical Coherence Tomography-Generated Corneal Thickness Maps.

PURPOSE: To report 2 cases of herpes simplex virus (HSV) stromal keratitis with epithelial ulceration that were managed using optical coherence tomography-generated pachymetric and corneal epithelial thickness maps. METHODS: Two patients with a history of HSV keratitis with nonhealing epithelial defects were referred to the Athens Vision Eye Institute. Anterior segment optical coherence tomography-generated pachymetric and corneal epithelial thickness maps showed subclinical stromal edema and irregular epithelium, thus indicating diagnoses of HSV stromal keratitis with epithelial ulceration. The patients were administered topical preservative-free dexamethasone and oral antiviral therapy. Steroid tapering was guided by pachymetric and corneal epithelial thickness maps at each follow-up visit. RESULTS: Both patients experienced initial healing of the epithelium and resolution of stromal inflammation. One patient had a recurrence of HSV stromal keratitis with epithelial defect 3 months after initial improvement, with pachymetric and corneal epithelial thickness maps indicating subclinical stromal edema. He was reintroduced to topical steroid therapy, and the stromal edema and epithelial defect subsequently resolved. Both patients have had no recurrences in the past year. CONCLUSIONS: Pachymetric and corneal epithelial thickness maps provide an objective assessment of stromal inflammation and the following 2 clinical advantages in the management of HSV stromal keratitis with epithelial ulceration: (1) they help differentiate it from HSV epithelial keratitis with geographic ulceration and neurotrophic keratopathy and (2) offer objective measurements to guide management with topical corticosteroids until resolution of stromal edema. Thus, treatment can be initiated in a timely manner, and the blinding complications of HSV stromal keratitis can be avoided.

Endothelial Cell Loss in Corneal Grafts From Donors Who Sustained Gunshot Wound to the Head or Airbag Deployment in a Motor Vehicle Accident.

PURPOSE: To compare the endothelial cell density (ECD) and quality of corneal grafts from young donors who sustained airbag deployment in motor vehicle accidents (MVA) or gunshot wounds (GSW) to the head with grafts from donors of similar age who died of other causes. METHODS: This is a retrospective comparative series of 65 corneal grafts from 33 young donors (mean age, 29.60 ± 8.95 yrs), with the cause of death either MVA with airbag deployment (n = 7), GSW to the head (n = 14), or other nontrauma-related cause (n = 12). Donor characteristics, graft quality on slit-lamp examination, ECD, and areas of endothelial cell loss on specular microscopy were compared between the groups. RESULTS: Donor age, graft quality on slit-lamp examination, and death-to-preservation time were similar between the groups. Statistically significant differences in focal areas of endothelial cell loss were found in the MVA- and GSW-derived grafts compared with the nontrauma-related grafts (85.7% vs. 0%, P value 0.0002 and 92.5% vs. 0%, P value <0.0001, respectively). Mean ECD was significantly lower in the 14 MVA-derived grafts (ECD, 3117 ± 218 cells/mm) and in the 27 GSW-derived grafts (ECD, 3234 ± 381 cells/mm) than in the 24 nontrauma-related grafts (ECD, 3511 ± 312 cells/mm, P values 0.0002 and 0.0068, respectively). No primary graft failures were reported for any of the grafts by masked observers. CONCLUSIONS: MVA- and GSW-derived grafts have lower ECD counts and more areas of endothelial cell loss compared with nontrauma-related grafts. Further studies are needed to evaluate long-term outcomes of such donor grafts.

Conjunctival Melanoma: Update on Genetics, Epigenetics and Targeted Molecular and Immune-Based Therapies.

PURPOSE: To present the molecular mechanisms involved in the pathogenesis of conjunctival melanoma (CM) and review the existing literature on targeted molecular inhibitors as well as immune checkpoint inhibitors for the management of locally advanced and metastatic disease. METHODS: A comprehensive review of the literature was performed using the keywords "conjunctival melanoma", "immune checkpoint inhibitors", "BRAF inhibitors", "MEK inhibitors", "CTLA4 inhibitors", "PD1 inhibitors", "c-KIT mutations", "BRAF mutations", "NRAS mutations", "dabrafenib", "trametinib", "vemurafenib", "ipilimumab", "pembrolizumab", and "nivolumab". A total of 250 articles were reviewed and 120 were included in this report. RESULTS: Mutations of mediators in the MAP kinase pathway, such as RAS, BRAF, MEK and ERK, and mutations of the PI3K/AKT/mTOR pathway play a major role in the pathogenesis of conjunctival melanoma. In addition, alterations of c-KIT, NF1, TERT, chemokine receptors as well as chromosomal copy number alterations and micro RNAs are thought to have a causative association with CM development. Targeted molecular inhibitors, such as BRAF and MEK inhibitors, are currently being implemented in the therapy of BRAF-mutated CM. Furthermore, immune checkpoint PD-1 and CTLA4 inhibitors with favorable clinical outcomes in the treatment of cutaneous melanoma have increased recurrence-free survival and reduced metastatic spread in CM cases. CONCLUSION: The complex molecular mechanisms that contribute to the development of CM can be targeted both by molecular inhibitors of oncogenic pathways as well as immune checkpoint inhibitors in order to halt progression of the disease and increase survival.

Intraocular Invasion of Ocular Surface Squamous Neoplasia Through a Corneal Wound.

PURPOSE: We report a case of intraocular invasion of ocular surface squamous neoplasia (OSSN) through a cataract surgery wound that manifested as an anterior chamber membrane, and perform a review of the literature. METHODS: An 87-year-old woman with history of an incompletely excised OSSN 10 days prior presented with decreased vision due to an anterior chamber membranous film that seemed connected to an old cataract wound. The membrane was biopsied, and histopathology revealed dysplastic squamous epithelial cells of conjunctival origin. Ten days later the tumor expanded to cover the entire iris surface, and a modified enucleation was performed. RESULTS: Histopathology revealed invasive OSSN extending deep to the ciliary body and laterally into the anterior chamber. The patient developed a submandibular node metastasis 7 months later. Literature review revealed six cases of invasive OSSN resulting from extension through a corneal wound, with varied presentations and outcomes. CONCLUSION: Our case is the first to report invasive OSSN presenting as an anterior chamber membrane as a result of incomplete excision of an ocular surface malignancy adjacent to a corneal wound poses a risk for intraocular tumor extension and distant metastasis.

Bilateral interstitial keratitis, erythema nodosum and atrial fibrillation as presenting signs of polyarteritis nodosa.

PURPOSE: To report a case of Polyarteritis Nodosa (PAN) presenting as bilateral episcleritis and interstitial keratitis along with erythema nodosum and atrial fibrillation and to review the ophthalmic literature on PAN with anterior segment findings. OBSERVATIONS: A 35-year old man presented with a two-month history of bilateral episcleritis, skin lesions consistent with erythema nodosum, joint effusions and episodes of prolonged diarrhea and atrial fibrillation. Ophthalmic examination was significant for bilateral diffuse episcleral injection and nummular corneal stromal infiltrates. The patient underwent an extensive infectious and inflammatory work-up that was negative except for a very elevated erythrocyte sedimentation rate (123 mm/h, normal < 20 mm/h) and C-reactive protein (51 mg/L, normal < 5 mg/L). In order to rule out inflammatory bowel disease upper endoscopy and colonoscopy were performed. Biopsies of the gastrointestinal mucosa were positive for a small- and medium-vessel necrotizing vasculitis consistent with polyarteritis nodosa. Disease control was achieved with systemic prednisone and azathioprine. Upon self-tapering both medications the patient developed hearing loss and interstitial keratitis recurred, hence the diagnosis of Cogan's syndrome/PAN was made. Intravenous pulse steroids were administered with resolution of his symptoms. The patient continues to be on azathioprine without disease recurrence for 1.5 years. Α review of the ophthalmic literature on PAN with anterior segment findings revealed only 10 cases; of these, 6 had originally presented with ocular manifestations alone (scleritis, peripheral ulcerative keratitis, episcleritis, dacryoadenitis) and 4 of these 6 were lethal due to delay in diagnosis. CONCLUSION AND IMPORTANCE: Early diagnosis of PAN is crucial, as the five-year mortality rate is close to 90%; upon initiation of systemic immunosuppression the mortality rate drops to 20%. Though PAN manifestations in the anterior segment are rare, a high index of suspicion is warranted in cases of bilateral episcleritis and interstitial keratitis.

Interactive online survey raises awareness about cornea donation.

OBJECTIVE: To assess the impact of a 5 min interactive online survey on raising awareness about cornea donation and willingness to become a donor. METHODS: An interactive online questionnaire was used to collect information regarding awareness, perceptions and attitudes towards cornea donation and to educate the participants about the process and value of cornea donation. Willingness to become a cornea donor was assessed at the beginning and the end of the survey. RESULTS: The survey was completed by 1769 Greek residents. Willingness to become a cornea donor increased from 40.5% (n=717) at the beginning of the survey to 55.2% (n=977) by the end of it (p<0.00001). Younger participants, those whose work or studies were unrelated to the medical field, and those with the least knowledge about cornea donation and transplantation were more likely to change their views towards donation by the end of the survey (42.3%, 44.8% and 82.1% increase in willingness to donate, respectively). Major deterrents to donation were lack of information, concerns about the use of the donated corneas and corruption within the medical field. CONCLUSION: Our 5 min online survey had a significant impact on changing the mentality towards cornea donation in Greece. We live in an online era and incorporation of online tools and applications in awareness campaigns towards cornea and organ donation has become a necessity.

Bilateral benign reactive lymphoid hyperplasia of the conjunctiva: a case treated with oral doxycycline and review of the literature.

BACKGROUND: To report a case of bilateral benign reactive lymphoid hyperplasia (BRLH) of the conjunctiva treated with oral doxycycline and perform review of the literature evaluating the presentation, treatment and risk of transformation to lymphoma. CASE PRESENTATION: A case report is described and review of the literature from January 1975 to January 2019 was performed. A 30-year-old man presented with bilateral enlarging fleshy pink medial canthal conjunctival lesions. Incisional biopsy revealed BRLH. Oral doxycycline was initiated (100 mg two times a day) for a total of 2 months. Both lesions decreased in size significantly at the patient's two-month follow up visit. The residual lesion in the right eye was excised along with an adjacent pterygium and the patient has been free of recurrence for the past 1.5 years. The lesion in the left eye has remained stable in size after cessation of the oral doxycycline. A total of 235 cases of conjunctival BRLH were identified in our literature search. The mean age at diagnosis was 35.2 years (range, 5 to 91 years). BRLH lesions were unilateral in 75% of patients and bilateral in 25% of them. Seven patients (2.9%) had a concurrent Epstein-Barr virus (EBV) infection at the time of lesion appearance. The most common treatments were surgical excision (155/235 or 65.9%) and corticosteroids (30/235 or 12.7%), while 14% (33/235) of the patients were observed and 4.6% (11/235) received external beam radiotherapy alone. Recurrence occurred in ten patients (10/235 or 4.2%), of whom five had undergone surgical excision alone, two excision followed by external beam radiotherapy, one excision and oral corticosteroids, one radiotherapy alone and one had been treated with topical corticosteroids. Overall, only 2 of the 235 reported cases (0.8%) developed malignancy, one localized to the conjunctiva and one systemic. CONCLUSIONS: Benign reactive lymphoid hyperplasia is one of the lymphoproliferative disorders of the conjunctiva and ocular adnexa. Extensive literature review shows that most cases are treated with surgery, steroids or observation. Oral doxycycline may be considered an alternative non-invasive treatment of BRLH conjunctival lesions. BRLH lesions warrant careful follow up as they can rarely transform into conjunctival or systemic lymphoma.

Medical and surgical management of conjunctivochalasis.

Conjunctivochalasis (CCH) is a bilateral conjunctival condition characterized by loose, redundant conjunctival folds, typically in the inferior bulbar conjunctiva. It is a common cause of ocular irritation, especially in older age. For asymptomatic CCH, no treatment is necessary. For treatment of symptomatic CCH, however, a variety of medical and surgical approaches are currently available, which will be thoroughly appraised in this review article. The first step in the management is medical therapy, which involves enhanced lubrication and use of anti-inflammatory medications. In refractory cases, a surgical approach may be undertaken for symptom relief. Several techniques have been described for this, with varying success rates. These include conjunctival cauterization, conjunctival excision, scleral fixation of the conjunctiva, conjunctival ligation, laser conjunctivoplasty, and radiowave electrosurgery. Among these, conjunctival cauterization and excision of the redundant conjunctiva, with or without tissue grafting, have gained popularity.