Virtual keratoconus monitoring clinic in a tertiary university hospital in the United Kingdom.

Purpose: To describe a new pathway for virtual keratoconus (KC) monitoring in the corneal department of a tertiary referral center in the UK during the coronavirus disease 2019 (COVID-19) pandemic. Methods: A virtual outpatient clinic to monitor KC patients (KC PHOTO clinic) was created. All patients from the KC database in our department were included. At each hospital visit, patients' visual acuity and tomography (Pentacam; Oculus, Wetzlar, Germany) were collected by a health-care assistant and an ophthalmic technician, respectively. The results were virtually reviewed by a corneal optometrist to identify stability or progression of KC and discussed with a consultant if needed. Those with progression were contacted by telephone and listed for corneal crosslinking (CXL). Results: From July 2020 until May 2021, 802 patients were invited to attend the virtual KC outpatient clinic. Of them, 536 patients (66.8%) attended and 266 (33.2%) did not attend. After corneal tomography analysis, 351 (65.5%) were stable, 121 (22.6%) showed no definite evidence of progression, and 64 (11.9%) showed progression. Forty-one (64%) patients with progressive KC were listed for CXL and the remaining 23 patients deferred treatment after the pandemic. By converting a face-to-face clinic to a virtual clinic, we were able to increase our capacity by nearly 500 appointments per year. Conclusion: In pandemic times, hospitals have developed novel methods of delivering safe patient care. KC PHOTO is a safe, effective, and innovative method of monitoring KC patients and diagnosing progression. In addition, virtual clinics can increase the clinic capacity tremendously and reduce the need of face-to-face appointments, which is beneficial in pandemic conditions.

Five Cases of Corneal Graft Rejection After Recent COVID-19 Vaccinations and a Review of the Literature.

PURPOSE: The purpose of this study was to report 5 cases of acute corneal graft rejection after COVID-19 vaccination and perform a review of the literature. METHODS: This was a case series and review of literature dated on the October 10, 2021. RESULTS: We describe 5 cases-2 patients with Descemet stripping automated endothelial keratoplasty (for Fuchs endothelial dystrophy) who presented with acute corneal graft rejection after their first dose of mRNA (BNT162) vaccine. The other 3 patients who had penetrating keratoplasty performed more than 10 years ago for keratoconus presented with acute graft rejection-2 patients after their second dose of adenovirus vector (AZD1222) vaccine and 1 patient after first dose of mRNA (BNT162) vaccine. Three patients were not using any topical steroid treatment at the time of diagnosis of graft rejection. The mean duration between vaccination and onset of symptoms was 16.86 ± 6.96 days for the mRNA vaccine and 17 ± 11.89 days for the adenovirus vector vaccine. CONCLUSIONS: Corneal graft rejection has recently been reported after COVID-19 vaccination. Patients with keratoplasty need to be advised regarding the risk of corneal graft rejection and warning symptoms of rejection after COVID-19 vaccination. Seeking early referral to the emergency department and increasing topical steroids pre-COVID-19 and post-COVID-19 vaccination may reduce the risk of rejection.

Impact of COVID-19 pandemic and lockdown on eye emergencies.

BACKGROUND: To characterise and compare ocular pathologies presenting to an emergency eye department (EED) during the COVID-19 pandemic in 2020 against an equivalent period in 2019. METHODS: Electronic patient records of 852 patients in 2020 and 1818 patients in 2019, attending the EED at a tertiary eye centre (University Hospitals of Leicester, UK) were analysed. Data was extracted over a 31-day period during: (study period 1 (SP1)) COVID-19 pandemic lockdown in UK (24th March 2020-23rd April 2020) and (study period 2 (SP2)) the equivalent 2019 period (24th March 2019-23rd April 2019). RESULTS: A 53% reduction in EED attendance was noted during lockdown. The top three pathologies accounting for >30% of the caseload were trauma-related, keratitis and uveitis in SP1 in comparison to conjunctivitis, trauma-related and blepharitis in SP2. The overall number of retinal tears and retinal detachments (RD) were lower in SP1, the proportion of macula-off RD's (84.6%) was significantly (p = 0.0099) higher in SP1 (vs 42.9% in SP2). CONCLUSION: COVID-19 pandemic related lockdown has had a significant impact on the range of presenting conditions to the EED. Measures to stop spread of COVID-19 such as awareness of hand hygiene practices, social distancing measures and school closures could have an indirect role in reducing spread of infective conjunctivitis. The higher proportion of macula-off RD and lower number of retinal tears raises possibility of delayed presentation in these cases. Going forward, we anticipate additional pressures on EED and other subspecialty services due to complications and associated morbidity from delayed presentations.

Fine-Needle Diathermy with Simultaneous Subconjunctival Bevacizumab.

PURPOSE: To describe our experience of the use of subconjunctival bevacizumab in conjunction with fine-needle diathermy for the treatment of corneal vascularization. METHODS: Retrospective analysis of cases treated between 2010 and 2013. RESULTS: Those patients with corneal lipid deposition had good results following treatment with 3/5 cases requiring more than one session of treatment. A single patient with severe atopy and multiple previous failed penetrating keratoplasty underwent five sessions of treatment but his third graft subsequently also failed. CONCLUSION: Concurrent use of subconjunctival bevacizumab with FND gives good results in patients with lipid deposition; however, the management of cases with ongoing inflammatory processes is much more challenging.

Refractive effect of reversed implantation of angled-haptic lens implants.

BACKGROUND: To study the refractive effect of reversed implantation of intraocular lenses. METHODS: Trigonometric calculations were used to calculate the extent of forward displacement of the optic for various lens designs available commercially. The SRK formula was used to estimate the relationship of axial length to the refractive power of the eye, with other variables remaining constant. RESULTS: The theoretical effect of a displaced posterior-chamber implant due to flipped insertion can vary from 1.46 dpt for a 12.5-mm diameter lens with an optic diameter of 6 mm (or a 13-mm diameter lens with an optic diameter of 6.5 mm) and a haptic angle of 5 degrees to 3.15 dpt for a 12.5-mm diameter lens with an optic diameter of 5.5 mm (or a 13-mm lens with an optic diameter of 6 mm) and a haptic angle of 10 degrees. CONCLUSIONS: There has been no study on the refractive effect of axial lens displacement due to a reversed implantation of a lens with a hinged haptic. This study identifies the major determinants (namely the haptic length and haptic angle) and gives an estimate of the effect on final refraction for each lens type commonly used when they are implanted on the reverse.

The use of voriconazole in the treatment of cylindrocarpon keratomycosis.

PURPOSE: To describe a rare form of fungal keratitis due to Cylindrocarpon lichenicola. METHOD: A 56-year-old woman presented with an atypical corneal ulcer that did not respond to broad- spectrum antibiotics. RESULTS: Additional diagnostic tests such as confocal microscopy and corneal biopsy were useful aids in establishing the diagnosis of fungal keratitis. The ulcer healed completely after the initiation of antifungal therapy. CONCLUSIONS: To the best of our knowledge, this is the first case of C. lichenicola keratomycosis in the United Kingdom. Our case demonstrates that prompt recognition and effective treatment of this condition can lead to a good visual outcome.

Failure of intracameral fluorouracil to resolve an epithelial ingrowth following clear corneal cataract surgery.

We present a case of epithelial ingrowth that progressed despite repeated intracameral injections of fluorouracil (5-FU). Six months after cataract surgery, a retrocorneal membrane was found advancing from the corneal section. At 1 year, 0.5 mg of 5-FU in 0.1 mL of balanced salt solution was exchanged for 0.1 mL of aqueous. Ingrowth initially stopped, but progressed 6 months later. Two further injections of 0.5 mg of 5-FU were given at 1-month intervals, followed by 1 mg of 5-FU 3 and 6 months later. Each injection initially halted progression of the ingrowth, but then it recurred. Ultimately, the treatment failed to prevent progression of the disease and angle-closure glaucoma ensued. Resolution of epithelial ingrowth with intracameral 5-FU has been reported twice. We found no reports of such treatment following clear corneal cataract surgery or with eventual epithelial ingrowth progression. Epithelial ingrowth remains a relentless and challenging condition to treat.

Multiplex bead analysis of vitreous humor of patients with vitreoretinal disorders.

PURPOSE: Vitreoretinal disorders are frequently characterized by increased vitreous levels of cellular mediators, including cytokines, chemokines, and growth factors. The study was conducted to investigate whether multiplex bead analysis could identify disease-specific profiles of these mediators in a variety of vitreoretinal diseases. METHODS: Levels of 19 mediators were measured: the cytokines IL-6, IL-10, IL-12, IL-13, IL-15, IL-17, TNF, IFN-gamma, granulocyte-macrophage-colony-stimulating factor (GM-CSF), and granulocyte-stimulating factor (G-CSF); the chemokines CCL2, CCL3, CCL4, CCL5, CCL11, and CXCL8; and the growth factors epidermal growth factor (EGF), FGF, and VEGF, by using multiplex bead analysis of vitreous humor of 58 eyes undergoing vitrectomy for a variety of vitreoretinal disorders. RESULTS: The predominant mediators detected were IL-6, CXCL8, and CCL2. The most complex pattern of mediators was seen in patients with proliferative vitreoretinopathy (PVR) and included a mixture of cytokines, chemokines, and growth factors. Patients with chronic uveitis showed a limited mediator pattern that did not suggest either a Th1 or Th2 response. By comparison, patients with lens-induced uveitis (LIU) showed significantly greater levels of cytokines than did patients with chronic uveitis, including IFN-gamma and IL-12, with a trend toward an acute Th1 inflammatory response. Moreover, in samples from patients with LIU, CXCL8 inversely correlated with time after initial surgery and duration of treatment. CONCLUSIONS: Multiplex bead analysis allows the measurement of multiple mediators from a single vitreous sample. The data confirm patterns of mediators previously described in different vitreoretinal conditions. In addition, LIU mediator levels correlate with duration of treatment and time after cataract surgery.

Topical glucocorticoid therapy directly induces up-regulation of functional CXCR4 on primed T lymphocytes in the aqueous humor of patients with uveitis.

Overexpression of the constitutive chemokine receptor CXCR4 has been shown to contribute to the accumulation of leukocytes at sites of chronic inflammation. Glucocorticoids are widely used to treat inflammatory disorders such as uveitis to considerable effect, yet paradoxically have been reported to increase CXCR4 expression in vitro. We show here that ocular lymphocytes isolated from patients with uveitis who had been treated with topical glucocorticoids expressed highly elevated levels of CXCR4. The up-regulation of CXCR4 could be reproduced in vitro by culture of CD4(+) T cells with aqueous humor (AqH), indicating a role for the ocular microenvironment rather than preferential recruitment of CXCR4(+) cells. Untreated uveitis and noninflammatory AqH up-regulated CXCR4 to a limited extent; this was dependent on TGF-beta2. However, the highest levels of CXCR4 both in vivo and in vitro were found in the glucocorticoid-treated patients. Glucocorticoids appeared to be directly responsible for the induction of CXCR4 in treated patients, as the glucocorticoid receptor antagonist RU38486 inhibited the in vitro up-regulation by AqH from these patients. Dexamethasone selectively up-regulated CXCR4 in vitro, but not any of a wide range of other chemokine receptors. CXCL12, the ligand for CXCR4, was present in AqH under noninflammatory conditions, but the levels were low in untreated uveitis and undetectable in treated uveitis AqH. The importance of these results for the treatment of HIV patients with glucocorticoids is discussed as well as a role for glucocorticoid-induced CXCR4 up-regulation and CXCL12 down-regulation in controlling the migration of lymphocyte populations, resulting in resolution of inflammation.

Solitary intracranial extra-osseous plasmacytoma presenting with ophthalmic signs.

Solitary plasmacytomas rarely develop in the skull, meninges, or brain. Ophthalmic signs as the initial manifestations of solitary intracranial plasmacytoma have rarely been described. We report the neuro-ophthalmologic, imaging, and pathologic findings for two patients. One patient presented with optic neuropathy, the second with bilateral sixth nerve palsies. Plasmacytoma is a treatable intracranial tumor that should be considered in the differential diagnosis of patients who present with optic neuropathy or sixth nerve palsy.