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Photorefractive keratectomy (PRK) was performed to treat corneal epithelial basement membrane dystrophy (EBMD) found after femtosecond laser-assisted laser in situ keratomileusis (FS-LASIK) in a 29-year-old man with previous silent cornea. The patient was diagnosed with post-FS-LASIK EBMD by slitlamp examination and in vivo confocal microscopy (IVCM). Initial treatment with topical lubricants and alcohol soaking was unsuccessful, and the patient continued to have blurred vision and discomfort. The patient underwent a PRK procedure, and the symptoms resolved dramatically; residual refractive errors were also corrected. IVCM revealed a characteristic presentation of EBMD before PRK and normal corneal epithelium after treatment. Patients with asymptomatic EBMD might suffer from recurrent corneal erosions after FS-LASIK. Surface ablation including PRK might lead to successful treatment outcomes, and IVCM might provide helpful information before and after treatment.

To determine the effects of epithelial basement membrane dystrophy (EBMD) and Salzmann nodular degeneration (SND) on optical biometry measurements.Department of Ophthalmology, Duke University Eye Center, Durham, North Carolina, USA.Retrospective case series.Cataractous eyes with EBMD or SND scheduled for superficial keratectomy (SK) or phototherapeutic keratectomy (PTK) had baseline biometry. Repeat biometry was performed 30 days or more postoperatively and compared with baseline. The primary outcome measures were keratometry (K) values, axial length and magnitude, and axis of corneal astigmatism. Secondary outcome measures were the change in intraocular lens (IOL) power, toricity, and axis.In the EBMD group (26 eyes), the mean absolute intersession difference showed an increase in mean K values (P .001) and a change in IOL spherical power predicting a postoperative spherical equivalent (SE) closest to zero (P .001) in 21 of 26 eyes (8 = 0.5 diopter [D]; 9 = 1.0 D; 4 1.0 D). In toric IOL-eligible eyes, the recommended IOL toricity changed for 16 of 24 eyes, with a mean cylinder power change of 1.2 D. In the SND group (13 eyes), the mean absolute intersession difference showed an increase in mean K values (P = .023) and a change in IOL spherical power predicting a postoperative SE closest to zero (P .001) in 11 of 13 eyes (3 = 0.5 D; 3 = 1.0 D; 5 1.0 D). The recommended IOL toricity changed for 10 of 11 eyes (mean cylinder power change 1.5 D).Both EBMD and SND altered K measurements as evidenced by clinically significant changes in keratometry after SK or PTK. These changes affected the spherical and toric IOL power. Appropriate management of EBMD and SND before cataract surgery can yield more reliable biometric data for surgical planning.

We describe two patients in whom postsurgical refractive error occurred after routine refractive lens exchange cataract surgery with multifocal intraocular lens insertion most likely attributable to the presence of underlying corneal epithelial basement membrane dystrophy (EBMD). In Case 1, there was an unexpected hyperopic postoperative spherical equivalent refractive error of +1.50 diopters and in Case 2, a cylindrical refractive error of 2.75 diopter cylinder. We examine the possible causes of error and discuss potential management strategies to prevent and address these unpredictable postoperative outcomes. The importance of comprehensive and careful ocular surface assessment before cataract or refractive surgery as part of the presurgical workup is reemphasized. EBMD can be subtle and if overlooked, can affect the validity of biometric keratometric measurements preoperatively, resulting in an inaccurate biometry measurement, incorrect IOL selection, and reduced visual performance and patient satisfaction.

Purpose To report the prevalence of ocular surface dysfunction in patients presenting for cataract surgery evaluation. Setting Duke University Eye Center and Weill Cornell Ophthalmology, single-physician practices. Design Prospective case series. Methods Consecutive patients presenting for cataract surgery evaluation were identified. Patient information including demographics, medical history, slitlamp findings, tear osmolarity, and tear matrix metalloproteinase-9 (MMP-9) levels were recorded. Patients were considered to have ocular surface dysfunction if any of the following outcomes were present: visually significant abnormal corneal surface examination, positive MMP-9 test, or abnormal osmolarity values (>307 mOsm/L or >7 mOsm/L intereye difference). Patient symptoms were recorded using the ocular surface disease index (OSDI) or Symptom Assessment iN Dry Eye questionnaires. Results There were 120 patients (69% women), mean age 69.5 years ± 8.4 (SD). Abnormal osmolarity was found in 68 patients (56.7%), and abnormal MMP-9 in 76 patients (63.3%). Clinical findings showed that 47 patients (39.2%) had positive corneal staining on presentation, 9 patients (7.5%) had epithelial basement membrane dystrophy, and 2 patients (1.6%) had Salzmann nodules. Questionnaire data showed 54 (54.0%) of 100 patients reported symptoms suggestive of ocular surface dysfunction. In the asymptomatic group of 46 patients, 39 (85%) had at least 1 abnormal tear test (osmolarity or MMP-9) and 22 (48%) had both tests abnormal. Overall, 96 (80%) of 120 patients had at least 1 abnormal tear test result suggestive of ocular surface dysfunction and 48 patients (40%) had 2 abnormal results. Conclusions Objective ocular surface dysfunction findings were common among patients presenting for cataract surgery, yet many presented undiagnosed. Clinicians should be aware of this high prevalence and consider screening with tear testing before surgery.

Purpose To determine the efficacy of epithelial debridement and diamond burr polishing (ED + DBP) in managing recurrent corneal erosion (RCE) and visually significant epithelial irregularity associated with epithelial basement membrane dystrophy (VS-EBMD). Methods Retrospective, interventional, consecutive case series of all ED + DBP procedures performed between December 1, 2002, and December 1, 2014. Results ED + DBP was performed in 91 eyes (66 patients) for the management of RCE and VS-EBMD. Sixty percent (55/91) of the procedures were performed for RCE, of which 65% (36/55) were associated with EBMD and 22% (12/55) with previous corneal trauma. Forty-six percent (42/91) of the procedures were performed for VS-EBMD, including 6 eyes with RCE. RCE resolved after treatment in 97% of eyes with >3 months of follow-up (mean, 33.2 months; range, 3.5-137.6 months). Corrected distance visual acuity (CDVA) and mean topographic astigmatism improved significantly in the 36 eyes treated for VS-EBMD with >1 month of follow-up. In none of the 22 eyes treated for VS-EBMD with >3 months of follow-up did EBMD recur (mean, 31.7 months; range, 3.2-137.6 months). Surgically induced subepithelial haze was present on last follow-up in 9.4% (8/85) of eyes with >1 month of follow-up, but was not associated with decreased final CDVA in any patient. Conclusions ED + DBP is effective in producing long-term resolution of RCE in 95% of treated eyes and significant improvement in CDVA, decreased topographic astigmatism, and long-term resolution of VS-EBMD in 100% of treated eyes.

Rationale: The etiology of anterior corneal opacities and the effect of debridement cannot be determined by biomicroscopy. Optical coherence tomography (OCT) helps identify the character and depth of these lesions. Patient concerns: A 45-year-old female complained of progressive blurred vision for a long time. Slit lamp biomicroscopy showed irregular, faint scar-like opacity of anterior cornea in her both eyes. Pentacam Scheimpflug camera tomography showed irregular astigmatism of anterior corneal surface. Anterior segment spectral-domain OCT revealed thickened, hyper-reflective linings, and scattered lesions, mainly in the epithelial layer. Diagnoses: Epithelial basement membrane dystrophy (EBMD). Intervention: Epithelial debridement and bandage lenses. Outcomes: The cornea became clear and the vision improved soon after debridement. The pathology showed thickened aberrant basement membrane extending into mid-epithelial layer, with microcyst-like lesions also noted. Lessons: OCT defines the depth of lesions and helps diagnosis and management of EBMD.

Purpose To describe the corneal findings in posterior polymorphous corneal dystrophy (PPCD) as imaged with laser scanning in vivo confocal microscopy (IVCM). Methods IVCM images of 7 subjects with PPCD who had typical slit-lamp biomicroscopic findings of endothelial vesicular, band, and/or placoid lesions were evaluated. Results Five women and 2 men aged 7 to 64 years were included in this study. Laser scanning IVCM (Heidelberg Retina Tomograph II, Rostock Cornea Module) revealed hyporeflective, round, vesicular lesions with diameters ranging between 20 and 200 µm in 3 subjects, combined vesicular and curvilinear hyperreflective band-like lesions in 3 subjects, and combined vesicular and placoid hyperreflective lesions in 1 subject at the level of Descemet membrane (DM), endothelial cell layer, and posterior stroma adjacent to DM. One subject had coassociated epithelial basement membrane dystrophy. Additional findings included posterior stromal keratocytes with elongated spindle-like nucleus, giant and nucleated endothelial cells, endothelial deposits, and guttae-like dark spots. The mean endothelial cell density was 1485.7 ± 486.3 cells per square millimeter (range, 990-2365 cells/mm). The mean central corneal thickness was 585.3 ± 37.17 μm (range, 534-643 μm). Conclusions Laser scanning IVCM is able to highlight the characteristic microstructural alterations at the level of endothelium and DM in the setting of PPCD and may have diagnostic utility in equivocal cases with borderline biomicroscopic findings. The possible association of PPCD with epithelial basement membrane dystrophy warrants further investigation.

To describe a patient with a history of epithelial basement membrane dystrophy who developed symptomatic corneal verticillata after vandetanib therapy for anaplastic astrocytoma.Retrospective interventional case report.A 48-year-old female patient with a history of anaplastic astrocytoma status post resection, external beam radiation, and chemotherapy presented with glare symptoms, decreased contrast sensitivity, and increased lacrimation after approximately 12 months of therapy with the anti-epidermal growth factor receptor (EGFR) and anti-vascular endothelial growth factor receptor 2 protein tyrosine kinase inhibitor, vandetanib. Ophthalmic examination revealed diffuse corneal verticillata and fine subepithelial opacities. Schirmer 1 testing was normal bilaterally. Therapy with carboxymethylcellulose, 5% sodium chloride ointment, and a decrease in the dose of vandetanib led to an improvement in the patient's ophthalmic symptoms despite persistence of the corneal findings. The patient remained under surveillance for tumor recurrence.Vandetanib (ZD6474), a protein tyrosine kinase inhibitor with dual anti-EGFR and anti-vascular endothelial growth factor receptor 2 action, may have contributed to the formation of corneal verticillata in our patient. Inhibition of EGFR, which is involved with corneal epithelial cell migration and wound healing, may play a role in the pathogenesis underlying corneal vortex keratopathy and ocular surface conditions with significant epithelial turnover.

PURPOSE To report a rare case of bilateral and symmetric Meesmann corneal dystrophy concurrent with bilateral epithelial basement membrane dystrophy and bilateral but asymmetric posterior polymorphous corneal dystrophy in a patient of Armenian origin. METHODS Complete ophthalmologic examination was performed on a 6-year-old boy from Armenia who was diagnosed with bilateral symmetric Meesmann corneal dystrophy combined with bilateral epithelial basement membrane dystrophy and bilateral but asymmetric posterior polymorphous corneal dystrophy. This case was observed and treated for 24 years. RESULTS On slit-lamp biomicroscopy, the patient showed bilateral multiple intraepithelial cystic lesions, bilateral irregularly shaped grayish-white opacities in the superficial corneal epithelium, and bilateral but asymmetric transparent vesicles surrounded by gray halos at the level of the Descemet membrane and the endothelium. CONCLUSIONS This case is reported because of the unusual occurrence of Meesmann corneal dystrophy with other corneal dystrophies.

Purpose To report the occurrence of large intraoperative epithelial sloughing during laser in situ keratomileusis (LASIK) as a first diagnostic sign for silent epithelial basement membrane dystrophy (EBMD). Setting Refractive Surgery and Cornea Unit, Alicante Institute of Ophthalmology, Alicante, Spain. Methods In this retrospective case series, the medical records of all patients with large corneal epithelial sloughing/defects during LASIK from January 1995 to December 2004 were reviewed. All patients who presented normal corneas before LASIK and EBMD changes after LASIK were included in this study. The surgical procedures and postoperative course were recorded. The follow-up period was 12 months for all patients. Results Eleven eyes of 6 patients were included. The mean age was 35 years ± 6.1 (SD). Mean preoperative uncorrected visual acuity (UCVA) was 20/500 (0.04 ± 0.02); 12 months after surgery, mean UCVA increased to 20/27 (0.74 ± 0.21). There was a significant decrease in best spectacle-corrected visual acuity 1 month after surgery. One year postoperatively, 10 of 11 eyes (91%) were within ±1.00 diopter of emmetropia. Postoperatively, clinical manifestations of EBMD were observed in all eyes and complications were common. In the early postoperative period, diffuse lamellar keratitis was observed in 6 of 11 eyes (54.5%) and flap microfolds were noted in 2 of 11 (18.2%). One year after surgery, epithelial ingrowth was present in 8 of 11 eyes (72.7%) and flap melting was noted in 4 of 11 (36.4%). Conclusion Occurrence of large intraoperative epithelium sloughing/defects during LASIK might be a diagnostic sign for subclinical EBMD. These patients are predisposed to multiple postoperative complications. Because of the high risk for epithelial sloughing in the second eye, LASIK should not be performed.

Epithelial basement membrane dystrophy, the most common hereditary anterior corneal dystrophy and considered a "category 1" dystrophy in some cases, encompasses microcystic dystrophy and other conditions affecting the epithelial basement membrane. The management of symptomatic epithelial basement membrane dystrophy includes alleviating blurred vision, treating recurrent corneal erosion, or both. Treatment of distorted vision may be as simple as prescribing lubricating drops and/or ointment, and posttrauma corneal erosion is often a limited problem that disappears over time and does not require laser or surgical treatment. This article describes treatment for more severe cases of corneal erosion, which includes mechanical debridement of the loosened epithelium.

Thirty eyes with symptomatic epithelial basement membrane dystrophy that were unresponsive to current standard modalities of therapy were treated with a total superficial epithelial keratectomy. Follow-up ranged from two months to 89 months (average, 37 mo). One hundred percent of patients were relieved of their preoperative symptoms, and only 3% have shown any evidence of recurrence of their dystrophic process.