One-Step Intraoperative Optical Coherence Tomography Guided Tunnel, Mushroom Femtosecond Laser Big Bubble Deep Anterior Lamellar Keratoplasty.

The aim of our study is to investigate the feasibility and outcomes of using a femtosecond laser (FSL) platform (Ziemer LDV Z8) for deep anterior lamellar keratoplasty (DALK), enabling the creation of mushroom-shaped graft-host junctions, lamellar cuts, and intrastromal tunnels, to facilitate the big bubble, in one step. We included wet lab experiments on nine porcine eyes to assess the laser accuracy and cuts depth using an anterior segment (AS) OCT. This was followed by an interventional prospective case series on 10 eyes with variant corneal pathologies. The Z8 system, with in-built intraoperative optical coherence tomography (iOCT), guided corneal scans and directed the cuts. ASOCT showed visible mushroom configurations, lamellar cuts, and tunnels. Deviations from the target were 1.6%, 2.6%, and 3.5%. Anterior lamellar removal was easy in all clinical cases, including corneal scarring. The intrastromal tunnel was found at the preset location and the mushroom configuration was acquired. A big bubble was achieved in all cases. Type 1, 2, and 3 bubbles were formed in eight, one, and one case, respectively. We describe a new approach to DALK in which the in-built iOCT-guided FSL enables safe, precise, controlled, and reproducible desired cuts in one step. The preliminary clinical outcomes were favorable.

Successful Collagen Crosslinking in a Patient With Keratoconus and Systemic Scleroderma.

Scleroderma is an autoimmune disease that affects connective tissue. Keratoconus (KC) is a rare ocular condition that may appear alongside scleroderma. Contact lenses are an essential visual aid for KC patients, especially in advanced cases. However, scleroderma patients may face difficulties using them due to finger-related disabilities. Corneal collagen cross-linking (CXL) is a crucial treatment used to prevent corneal thinning and visual deterioration in progressive KC. However, the potential trigger of corneal melt and delayed healing following CXL in KC patients with scleroderma is a matter of concern. We present a case of a patient with KC and scleroderma who underwent CXL without any complications.

The Protective Effect of Rho-Associated Kinase Inhibitor Eye Drops (Ripasudil) on Corneal Endothelial Cells After Cataract Surgery: A Prospective Comparative Study.

INTRODUCTION: Cataract surgery poses a risk to corneal endothelial cells. This study aimed to assess the protective effect of rho-associated kinase inhibitor eye drop (ripasudil) on corneal endothelial cells after cataract surgery over 12 months. METHODS: We conducted a prospective, non-randomized, non-blinded comparative study including 43 patients divided into two groups: the ripasudil group (22 patients, 23 eyes) and the control group (21 patients, 21 eyes). All patients had grade 3 nuclear cataract and underwent uneventful phacoemulsification with intraocular lens implantation. In the ripasudil group, one drop of ripasudil hydrochloride hydrate (Glanatec® ophthalmic solution 0.4%) was administered three times a day for 5 days. Outcome measures included central corneal thickness (CCT) and endothelial cell density (ECD), which were evaluated preoperatively and 12 months postoperatively. RESULTS: In the ripasudil group, the median ECD was 2398 (interquartile range [IQR] 410, 2201-2611) cells/mm2 at baseline and 2262 (IQR 298, 2195-2493) cells/mm2 at 12 months postoperatively. In the control group, the median ECD was 2503 (IQR 390, 2340-2730) cells/mm2 at baseline and 2170 (IQR 324, 2049-2373) cells/mm2 at 12 months postoperatively. Endothelial cell loss (ECL) was 12.8% in the control group, significantly reduced to 4.5% in the ripasudil group (p = 0.001*). CCT (p = 0.042), age (p = 0.383), sex (p = 0.944), and duration of surgery (p = 0.319) were not significant factors. No adverse effects were observed in either of the groups. CONCLUSIONS: Incorporating ripasudil into postoperative management could help maintain corneal endothelial cell integrity and reduce cell loss after cataract surgery, potentially decreasing the need for endothelial transplantation in patients who have undergone intraocular surgeries.

Salmon patch-like conjunctival lesion secondary to long-term administration of topical brimonidine: A case report.

INTRODUCTION: Brimonidine is a commonly used intra-ocular pressure-lowering agent for glaucoma patients. Allergic follicular or papillary conjunctivitis is a well-known side effect of brimonidine. Brimonidine is associated with ocular allergic symptoms such as conjunctival hyperemia, stinging sensation, photophobia and, in severe cases, corneal erosions. Here, we report a case of atypical conjunctival lesion following long-term administration of brimonidine. CASE PRESENTATION: We report the clinical findings of a 72-year-old female presenting with a salmon patch-like conjunctival lesion affecting the bulbar and palpebral conjunctiva after long-term use of brimonidine. The finding was suspicious of conjunctival lymphoproliferative disorders. However, upon cessation of brimonidine, along with the administration of short-course topical steroid, a complete resolution of the lesion was evident. Biopsy was not performed as the clinical picture improved with conservative management. No recurrence was observed over 1 year follow up. DISCUSSION: Atypical conjunctival lesions have been described after long-term use of brimonidine. These lesions can mimic the appearance of conjunctival tumors, specifically conjunctival lymphoproliferative disorders, for which multiple investigations are required including invasive conjunctival biopsy. CONCLUSION: Careful observation is recommended for patients with a history of long-term use of brimonidine for the development of atypical conjunctival lesions which may simulate the appearance of conjunctival lymphoproliferative disorders.

Three-years outcomes of simultaneous photorefractive surgery and customized corneal cross-linking for keratoconus.

PURPOSE: To report the efficacy of customized cross-linking (CXL) in halting progression of keratoconus when combined with photorefractive procedures. METHODS: Seven eyes from 7 patients with documented progressive keratoconus were treated with customized CXL (customized ultraviolet-A irradiance pattern centered on the maximum posterior elevation with total energy levels ranging from 5.4 up to 10 J/cm2 , and an energy fluence of 9 mW/cm2) combined with photorefractive procedures. Four patients underwent simultaneous transepithelial photorefractive keratectomy (T-PRK) plus customized CXL, and three patients underwent simultaneous transepithelial phototherapeutic keratectomy (T-PTK) plus customized CXL. Tomographic parameters (Kmax, pachymetry of the thinnest point and maximal elevation of posterior float and regularization index) and best spectacle-corrected visual acuity (BSCVA) were compared preoperatively and 3 years postoperatively. RESULTS: All eyes showed a decrease in the maximal curvature Kmax, and none of eyes showed progression. Six eyes showed a flattening of 3 or more diopters (D). On average, Kmax decreased by - 4.8 ± 2.5 D, and the BSCVA improved by 0.04 ± 0.07 logarithm of the minimal angle of resolution. The mean value of regularization index was 8.7 ± 3.8 D. Mild corneal haze occurred in two eyes, and superficial apical scar occurred in one eye. None of the eyes had a vision-threatening complication. CONCLUSION: Customized CXL combined with photorefractive procedure (T-PRK/T-PTK) resulted in long lasting flattening effect and strong regularization of keratoconic corneas along with improvement of BSCVA over a 3-year follow-up.

Pull-through insertion of EndoArt for complex eyes.

Purpose: To report an alternative technique to implant the EndoArt using a pull-through insertion. This technique is helpful in complex eyes, especially in eyes with unstable iris lens diaphragm. Observation: We present a case of advanced pseudophakic bullous keratopathy with aniridia, previous vitrectomy, and tube implants in which the initial attempt to implant the EndoArt failed, and the device was lost to the vitreous cavity. An alternative surgical technique, a pull-through insertion, was used to implant a second device successfully. The patient was followed over a period of 1 year. Corneal edema gradually improved over time, and all epithelial bullae resolved. The central corneal thickness (CCT) decreased from 911um to 691 µm. Conclusion and Importance: EndoArt is a treatment for endothelial failure in complex eyes. In addition, the pull-through insertion technique can help improve control over the implant in very complicated eyes.

Femtosecond laser assisted superficial lamellar keratectomy as a successful treatment of corneal opacity in a patient with Thiel Behnke corneal dystrophy.

INTRODUCTION AND IMPORTANCE: Thiel Behnke corneal dystrophy (TBCD) and Reis Buckler corneal dystrophy (RBCD) are Bowman's layer dystrophies with overlapping clinical features causing diagnostic confusion. However, each entity has typical histopathological features. We describe in this case the successful use of Femtosecond laser (FSL) in the treatment of TBCD-related corneal opacity. CASE PRESENTATION: We present a 54-year-old male with bilateral superficial corneal opacities consistent with TBCD based on clinical appearance, anterior segment optical coherence tomography (AS-OCT), and In vivo confocal microscopy. Management options were discussed with the patient before proceeding with Femtosecond Laser Assisted Superficial Lamellar Keratectomy (FSLASLK). The histopathological findings of the excised left anterior lamellar corneal flap were typical of TBCD and the patient had a satisfactory outcome. CLINICAL DISCUSSION: TBCD typically affects Bowman's layer centrally with progressive opacities involving the deeper layer of the corneal stroma and the periphery with advancing age. Histopathology typically shows subepithelial fibrosis with interrupted basement membrane and totally replaced Bowman's layer by uneven fibrous tissue forming the characteristic saw tooth pattern. The treatment of such cases is challenging with variable success and recurrence rates. Our case was managed successfully using FSL. CONCLUSION: TBCD, even though a rare type of dystrophy, should be suspected based on the appearance of the corneal opacities clinically. It can be diagnosed by typical AS-OCT findings supported by histopathological confirmation and can be successfully treated by FSASLK.

Paraneoplastic pemphigus associated with rapidly progressing endophthalmitis caused by Morganella Morganii: A case report.

INTRODUCTION: The ocular presentation of paraneoplastic pemphigus (PNP) has rarely been reported in the literature. In this report, we describe a 61-year-old male presenting with eruptive skin lesions associated with underlying non-Hodgkin's lymphoma who had rapid progressive corneal perforation with secondary endophthalmitis in the setting of PNP. CASE DESCRIPTION: A 61-year-old male presented to the emergency department complaining of skin eruption mimicking Stevens-Johnson syndrome, which was later found to be related to PNP. Initially, the patient complained of progressive ocular surface dryness in both eyes. Meanwhile, he developed mild pain in the right eye associated with blurry vision in both eyes and was managed with lubricants and topical antibiotics. A few days later, he was found to have corneal perforation with features suggestive of left endophthalmitis with possible early panophthalmitis. Intravenous antibiotic was administered, and primary evisceration of the left globe was performed. Histopathology revealed acute necrotizing keratitis and endophthalmitis. Vitreous analysis showed numerous gram-negative bacilli and a positive culture of Morganella morganii. The patient continued to be managed with frequent lubrications and punctual plugs in the fellow eye during the follow-up period. CONCLUSION: We describe the first case of endophthalmitis developing secondary to PNP-induced corneal melting and perforation. Anticipating unusual infectious sequelae in the setting of PNP might be warranted to actively detect and successfully manage dry eye disease before devastating complications develop.

Histopathological assessment of optic nerve invasion guided by radiological findings in enucleated globes with retinoblastoma.

BACKGROUND: Optic nerve (ON) invasion is an important high-risk feature, and an indicator for neoadjuvant chemotherapy and prognosis. We aim through this study to correlate the detected-ON invasion by Magnetic resonance imaging (MRI) with the corresponding confirmed histopathological level of invasion. METHODS: A retrospective study of enucleated globes with the diagnosis of retinoblastoma received in the histopathology department(s) from January 2015 to December 2016 (2 years). Slides were reviewed for ON invasion assessment, charts were reviewed for basic demographic data. All patients underwent MRI under sedation upon diagnosis and MRI findings were collected for the above correlation. RESULTS: A total of 38 patients were included: 21 males and 17 females. 29 (77.3%) had unilateral involvement, 7 (18.4%) had bilateral involvement and 2 cases had trilateral disease. The overall mean age at diagnosis was 22.63 ± 15.15 months. Histopathological examination revealed ON invasion in 28 cases (74%) distributed as follows: prelaminar (31.6%), laminar (18.4%), and post-laminar (23.7%). MRI confirmed post-laminar ON invasion in 8 cases (true positive) but failed to detect this in 1 case. Additionally, MRI detected another 8 cases of ON invasion that were false positive on histopathology (accuracy: 63.3%; sensitivity: 88.9%; specificity: 72.4%; Positive predictive value (PPV): 50%; Negative predictive value (NPV): 95.5%). CONCLUSIONS: MRI is found to be less sensitive in evaluating prelaminar and laminar ON invasion (0.0 and 42.9%) compared to post-laminar invasion (88.9%). MRI has generally better specificity in detecting ON invasion irrespective of the invasion level. In our study, obtaining deeper and/or additional histologic sections from the other surface of the tissue block in cases where a post-laminar ON invasion by MRI is found but not confirmed histopathologically in routine sections is essential to avoid missing such an important high-risk feature.