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Ophthalmic surgical operating lists include intraocular and extraocular procedures, as well as clean non-infectious and dirty infectious cases. Patient age, diabetic status, local or general anaesthesia must be considered during ophthalmic theatre scheduling. Traditionally children and ‘clean cases’ are prioritised. However, factors such as the need for an interpreter, patient transport and latex allergy affect the sequencing of ophthalmic lists. An electronic survey was sent to all UK ophthalmology consultants through the Royal College of Ophthalmologists registry, enquiring about their preference in sequencing mixed theatre lists, what operations they considered clean and dirty, and the presence of departmental protocol for list sequencing. There was a 16.9% response rate ( n = 222/1311). A majority of 75.2% ( n = 167/222) had mixed operating lists of intraocular and extraocular cases. Of those performing mixed operating lists, 44.3% ( n = 74/167) stated they would operate on intraocular cases before extraocular cases, and 92.8% ( n = 155/167) would perform ‘clean’ before ‘dirty’ cases. Fifty-nine per cent ( n = 98/167) have a departmental protocol to help determine list order. This survey has demonstrated that there is a trend to perform ‘clean’ before ‘dirty’ and intraocular before extraocular cases. Given the results of the survey, we outline our recommendation on how to sequence mixed ophthalmic theatre lists.

Purpose: To describe a novel technique of amniotic membrane (AM) patch graft in the management of double chamber treatment after big-bubble deep anterior lamellar keratoplasty (DALK). Case Report: A 35-year-old male patient with advanced keratoconus underwent big-bubble DALK. Manual lamellar dissection was done due to failed big-bubble. First-day postoperative double chamber was detected. Air bubbling and SF6 injection were tried without any success. Double chamber resolved by fixation of AM transplantation patch graft (1 × 1 mm) over the Descemet's membrane perforation with fibrin glue. Conclusion: Amniotic membrane patch graft can be used in the management of double chamber after DALK not responsive to intracameral gas injection.

BACKGROUND: Cataract extraction is the most frequently performed surgical intervention in the world and demand is rising due to an ageing demography. One option to address this challenge is to offer selected patients immediate sequential bilateral cataract surgery (ISBCS). This study aims to investigate patient and operative characteristics for ISBCS and delayed bilateral cataract surgery (DSCS) in the UK. METHODS: Data were analysed from the Royal College of Ophthalmologists' National Ophthalmology Database Audit (NOD) of cataract surgery. Eligible patients were those undergoing bilateral cataract extraction from centres with a record of at least one ISBCS operation between 01/04/2010 and 31/08/2018. Variable frequency comparison was undertaken with chi-square tests. RESULTS: During the study period, 1073 patients had ISBCS and 248,341 DSCS from 73 centres. A higher proportion of ISBCS patients were unable to lie flat (11.3% vs. 1.8%; p

Purpose To assess the attitudes and beliefs held toward immediate sequential bilateral cataract surgery (ISBCS), including estimating the incidence of European Society of Cataract and Refractive Surgeons (ESCRS) members currently performing ISBCS, exploring the barriers of ISBCS implementation, and assessing the relevance of these findings to practice in the United Kingdom. Setting European consultant members of the ESCRS. Design Survey-based questionnaire. Methods The survey was sent and collected electronically. An initial screening question directed the rest of the survey; participants were asked to rate the importance of several factors with regard to performing ISBCS. Free text options were also available. Descriptive analysis was performed. Results Of the 2200 recipients, 303 (13.7%) responded, of which 247 were eligible for analysis. Of the 247 eligible respondents, 166 (67.2%) reported performing ISBCS, 71 (28.7%) said they did not perform ISBCS, and 10 (4.0%) said they had previously done so but have since stopped. Of those who were currently practicing ISBCS, the three most important factors to consider were all directly related to infection risk. Of those who did not perform ISBCS, the most important reasons for not performing the surgery were a risk for endophthalmitis (69.0%) and the medicolegal issues should ISBCS go wrong (57.8%). The most common reason for stopping ISBCS was that the respondent no longer believed in the benefit of ISBCS (n = 4). Conclusions The survey reflects ophthalmologists' concerns regarding infection and medicolegal risks; however, reports of bilateral endophthalmitis are extremely rare when the correct recommendations are followed. The findings from this survey could be used to inform service provision of ISBCS in the U.K., taking into consideration the voices of colleagues overseas.

Purpose: To present our experience in Osteo-odonto-keratoprosthesis (OOKP) as the only option to restore vision after severe ocular dog bite injuries. Methods: We describe our results in OOKP performed in two patients with previous severe dog bite facial injuries that required exenteration of one eye and facial reconstruction. Results: Both cases achieved initially successful anatomical and visual outcome; however, one case suffered retinal detachment after one year. Buccal mucosa (BM) ulcerations and tilted lamina were present as a result of extraocular muscles loss, and both were difficult to treat. Conclusion: OOKP has the capability to restore vision in the most challenging cases of ocular trauma; however, refractory BM ulcerations and tilted lamina could be expected as a result of an ischemic ocular surface and orbital pulleys loss. Keywords: Osteo-odonto-keratoprosthesis, Keratoprosthesis, Dog bite ocular injury

A significant increase in prevalence of cataract is anticipated over the next two decades due to increasing life expectancy. This demands an increase in capacity of eye care services which is limited by insufficient human resources including ophthalmologists and inadequate financial investment in this field. Developing new systems for cataract surgery delivery can be part of the solution to fulfill this demand. One promising approach is immediately sequential bilateral cataract surgery (ISBCS). It has attracted attention of ophthalmologists in different countries. Although there are some studies to compare outcomes of this style to traditional one, many aspects of this approach remain controversial. Improvement in efficacy of referral for cataract surgery and patient flow in eye care units is another crucial step.

To evaluate corneal subbasal nerve plexus by in vivo confocal microscopy (IVCM) following punctal occlusion in patients with moderate to severe dry eye disease (DED).Patients with grade 3 or 4 severity of DED based on Delphi Panel dry eye severity grading scheme were enrolled in the study. Permanent inferior punctal occlusion was performed. A comprehensive ophthalmic evaluation, including Ocular Surface Disease Index (OSDI) questionnaire, tear break-up time (TBUT), corneal fluorescein staining, conjunctival Rose bengal staining, Schirmer's test, and corneal sensation by Cochet-Bonnet esthesiometry, were performed at baseline, and 1 and 3 months after punctal occlusion. Furthermore, density and number of corneal subbasal nerves were evaluated by IVCM.Forty-one eyes of 23 patients with a mean age of 46.3 ± 9.0 years were enrolled. Corneal fluorescein staining, Rose bengal staining, and TBUT significantly improved at 3 months following punctal occlusion (Corneal subbasal nerve density and total number increased following punctal occlusion in patients with moderate to severe DED. These findings were associated with improvements in corneal sensation, and signs and symptoms of DED. This emphasizes the effect of punctal occlusion in regeneration of corneal subbasal nerve plexus.

Purpose To analyze and review the clinical features and main outcomes of laminar resorption from the UK osteo-odonto-keratoprosthesis (OOKP) cohort. Methods A retrospective review of case records was undertaken for patients who underwent keratoprostheses between 1996 and 2014 at the Sussex Eye Hospital, Brighton, UK. The main clinical outcomes of resorption, including its clinical signs, complications, treatments, and laminar survival, were evaluated. Results Sixty-four patients (25-females, 39-males) were included, and in total, 74 laminae (3-tibial, 11-allografts, 60-autografts) were implanted. The age of the patients ranged from 20 to 91 years. Focal laminar thinning was the first sign of detectable resorption in 50% of autografts and 27% of allografts. All the tibial grafts and 55% of allografts presented with complications of resorption like endophthalmitis and aqueous leakage as the first signs of resorption. The survival of first implanted autografts was 82.4%(±6.3%) at 18 years, which was enhanced to 91.5%(±5.0%) by prophylactic exchanges of critically resorbed laminae with new laminae. Visual acuity survival analysis did not reveal a statistically significant difference between grafts with and without resorption for all graft types (p = 0.825). Patients treated with Alendronic acid and acetazolamide demonstrated trends toward the slower progression of resorption, but this was not statistically significant. Conclusions Focal laminar thinning was the common presenting feature of resorption in autografts. Timely replacement of the resorbed laminae with new laminae should be considered to avoid complications. Alendronic acid supplementation may be considered in high-risk cases of resorption to reduce further progression.

Purpose: To compare the effectiveness of onion extract, topical steroid, and petrolatum emollient in the prevention of scars in cases who underwent bilateral upper eyelid blepharoplasty. Methods: A prospective, interventional, comparative, double-blinded case series was designed on cases who underwent upper lid blepharoplasty. After suture removal (1 week following the surgery), the eyelids of participants were randomly allocated into the three groups: The first group used onion extract on the right eyelids (n = 18), and the second group used topical steroid on the right eyelids (n = 19). In the third group, the control group, petrolatum emollient was used on the left eyelids (n = 37) of the first and second group's cases. They used drugs for 2 months and were evaluated by the Manchester Scar Scale (MSS) objectively by two graders who were blinded to the type of medication. MSS evaluates five different characteristics of the scar in addition to the Visual Analog Scale (VAS). These characteristics include color, distortion, contour, texture, and transparency. VAS scores the overall scar appearance which ranged among 0–10. The sum of the scores for the five different parameters, and VAS was calculated, analyzed, and compared among the groups. Results: A total of 37 cases (74 eyelids) who underwent bilateral upper blepharoplasty were included. The mean ± standard deviation (SD) of age was 51.94 ± 9.26 years, 49.40 ± 9.37 years, and 47.00 ± 9.06 years in the onion extract, topical steroid, and petrolatum emollient groups, respectively (P = 0.275). There were no statistically significant differences in the mean ± SD of the sum of the MSS scores among the three groups (P = 0.924) or between the onion extract and topical steroid groups (P = 0.951). Furthermore, the color, distortion, contour, texture, transparency, and VAS scores were not statistically significantly different among the three groups or between the onion extract and topical steroid groups (P > 0.05). Conclusion: There were no significant differences among these three groups of drugs regarding the appearance of the upper blepharoplasty scar.

Background The standard approach to treat cataracts is Delayed Sequential Bilateral Cataract Surgery (DSBCS), during which patients have a separate operation date for each eye. An alternative method of delivery is Immediately Sequential Bilateral Cataract Surgery (ISBCS). The aim of this project was to examine the attitudes and beliefs of UK ophthalmologists towards ISBCS, explore their reasons to either practise or not practise ISBCS and identify barriers hindering its implementation in the UK. Methods A questionnaire was distributed to consultant members of The Royal College of Ophthalmologists (RCOphth, UK) and collected electronically. An initial screening question in regards to prior experience with ISBCS directed the rest of the survey; participants were asked to rate the importance of several factors with regards to performing ISBCS. Free text options were also available. Descriptive analysis was subsequently performed. Results Of the 1357 recipients, 130 (9.6%) ophthalmologists completed the survey. Of those, 13.9% were currently performing ISBCS, 83.1% had never performed, and 3.1% had previously done so but since stopped. The main factors that acted as barriers were lack of: (1) College approval (20.5%); (2) medico-legal approval (20.2%); (3) evidence to support the use of ISBCS (16.0%); and (4) hospital approval (13.3%). Additionally, the perceived risk of complications for patients played an important role when considering ISBCS, with the risk of endophthalmitis being most feared. Conclusions This survey demonstrates some of the barriers that prevent ophthalmologist’s performing ISBCS in the UK. There is a need for further exploration in this field to evaluate the effect of addressing any of these concerns on the implementation of ISBCS.

To evaluate in vivo confocal microscopy (IVCM) findings of ocular surface squamous neoplasia (OSSN) during treatment with topical interferon alfa-2b (IFN alfa-2b).In this prospective interventional case series, 20 eyes from 20 patients with OSSN were treated with topical IFN alfa-2b 3 million IU/mL four times a day. Treatment was continued for 2 or 3 months after clinical resolution. IVCM was done at baseline, on a monthly basis, and at the end of treatment. Confocal images were evaluated in conjunction with clinical findings during treatment. Limbal dendritic cell (DC) density within the involved areas was calculated manually in confocal images.Topical therapy resulted in clinical resolution of neoplasia in 80% of eyes. Main features of OSSN on IVCM were hyper-reflectivity of epithelium, demarcation line between neoplastic and normal epithelium, and pleomorphic cells. These findings became less prominent in response to IFN alfa-2b therapy. However, some degree of residual epithelial hyper-reflectivity could be detected in 9 (56.2%) subjects who responded to therapy at time of treatment cessation. Limbal DCs density within involved areas was significantly increased at month 1 follow-up compared to baseline only in responders (P .0001). There was a trend toward higher limbal DCs density in responders to topical IFN alfa-2b than non-responders (208.6 ± 53.5 vs. 153.1 ± 48.2 cell/mmIVCM is proposed as an adjunctive tool for monitoring OSSN during topical treatment. IVCM documents epithelial cell response as well as limbal DC density increase during topical IFN therapy.

To review and compare the published reports of Descemet membrane endothelial keratoplasty (DMEK) and Descemet stripping endothelial keratoplasty/Descemet stripping automated endothelial keratoplasty (DSEK/DSAEK) procedures with regard to endothelial cell density/loss, best spectacle-corrected visual acuity, central corneal thickness, subjective outcomes (patient's reported satisfaction/preference), and postoperative complications.A thorough search was conducted in the databases including AMED, EMBASE, Cochrane Database of Systematic Reviews, and MEDLINE without date restrictions. Systematic reviews, meta-analysis, randomized controlled trials, case series, and audits comparing DMEK and DSAEK were included.DMEK is superior to DSAEK for the following outcomes: visual acuity, central corneal thickness, and patient satisfaction. There was a statistically significant difference in the mean spectacle-corrected visual acuity at 6 months for DMEK (mean = 0.161, SD = 0.129) and DSAEK eye (mean = 0.293, SD = 0.153) conditions; t (297) = 8.042, P0.0001. The pooled mean difference was -0.13 (95% confidence interval, -0.16 to -0.09) and I = 44%, indicating better visual acuity for DMEK. Mean postoperative endothelial cell density showed statistically no significant difference in the mean values for DMEK (mean = 1855, SD = 442) and DSAEK eye (mean = 1872, SD = 429) conditions; t (336) = 0.375, P = 0.708. A higher proportion of patients prefer DMEK to DSAEK. However, DSAEK is superior to DMEK with respect to the need for rebubbling as the rebubbling rate was higher in the DMEK group.Although DMEK is associated with a higher rate of rebubbling, better visual outcomes were seen in DMEK.

Purpose To evaluate the safety and efficacy of tacrolimus eye drops as adjunctive therapy in the treatment of severe corneal endothelial rejection after penetrating keratoplasty refractory to corticosteroids. Methods In this prospective interventional case series, 11 eyes of 11 patients assessed for severe corneal endothelial rejection, with an inadequate response to topical, local, and systemic corticosteroids, were treated with either 0.01% or 0.05% tacrolimus eye drops 4 times daily. Improvement in signs of rejection, visual function, and development of complications were monitored. Results The duration of steroid treatment before intervention was 8.1 ± 1.4 days (range = 7-11). Patients were subsequently administered topical tacrolimus 0.01% or 0.05% qid. The time to clinical improvement was 10.3 ± 3.4 days (range = 3-17). The time to rejection reversal was 27.8 ± 16.3 days (range = 7-52). After 3 months, 10 patients (90.8%) demonstrated clinical improvement, and complete restoration of graft clarity was achieved in 5 patients (45.4%). In responsive cases, steroid therapy was successfully tapered off after 60.2 ± 19.7 days (range = 36-93). The best spectacle-corrected visual acuity improved from 1.7 ± 0.9 to 0.8 ± 0.5 logMAR (P = 0.0016). Reported side effects included stinging on drop instillation and punctate epithelial keratopathy. Conclusions Tacrolimus eye drops may be able to play an adjunctive therapeutic role in patients with severe corneal endothelial rejection refractory to conventional steroid treatment. Controlled studies are needed to further investigate the role of tacrolimus in this setting.

Purpose of review To describe the practice of and recent developments in the osteo-odonto-keratoprosthesis. Recent findings Formal psychological assessment and support have been described. A sub-aqua system for fashioning the osteo-odonto-keratoprosthesis lamina; adoption of thicker laminae; use of bisphosphonate drugs; advances in laminar imaging; and use of bone augmentation and bone morphogenetic protein have been described for prevention, detection, and management of laminar resorption. Two systems of optical cylinders available commercially. A stepladder approach to buccal mucous membrane overgrowth onto the optical cylinder has been described, including use of mitomycin-C. Orbital decompression has been used for cosmetic improvement. Detection of glaucoma may be aided by an intraocular pressure sensor, whereas surgical treatment is mainly by way of glaucoma drainage devices, as endolaser ciliary ablation and recti muscle disinsertion and reinsertion not having prolonged and significant long-term beneficial effect. Sublingual timolol has been described. The use of endoscopy has been proposed for preoperative evaluation of the posterior segment, ciliary ablation and for vitreoretinal surgery although wide-angle viewing systems remains standard practice. Summary The osteo-odonto-keratoprosthesis is the procedure of choice for rehabilitation of corneal blindness for end-stage ocular surface disease, serving a completely different patient group to the Boston Type 1 KPro.

The Cornea and Conjunctiva represents the components of the ocular surface; the Cornea is the transparent structure with optical functions and the Conjunctiva constitutes the remaining part of the ocular surface covering the sclera. The ocular surface may be affected by a variety of disorders, caused by a variety of external or internal pathogens. The basics, mechanism and treatment of these diseases will be briefly discussed in this chapter.

To introduce an assessment tool (rubric) for evaluating ophthalmology residents' competency in pterygium surgery.A panel of experienced international surgeons collaborated and developed the rubric. After describing various stages of the procedure, the Dreyfus scale of skill acquisition was used for scoring each stage. After finalizing the rubric, two surgeons independently evaluated 20 masked pterygium surgery videos of 10 residents and scored the videos according to the rubric. The agreement between the scores of them was examined with the intra-class correlation coefficient test.This rubric divides pterygium surgery into 13 different stages and covers the two most common techniques of pterygium surgery; conjunctival autograft and amniotic membrane transplant. The rubric showed face and content validity. Overall, an intraclass correlation coefficient of 0.90 (95% confidence interval 0.76-0.96, P 0.001) was achieved between the two surgeons. The residents scored significantly higher on surgeries performed later in their rotation compared to the earlier surgeries (4.32 ± 0.35 vs 3.96 ± 0.31, P = 0.006). Certain stages of pterygium surgery were more strongly correlated with the residents' past pterygium surgical experience.This study introduces an international rubric for assessing competency in pterygium surgery. In addition to face and content validity, this rubric shows high inter-rater reliability. This may be a useful tool for teaching and measuring competency in pterygium surgery.

Effective prophylaxis and treatment of corneal graft rejection are essential to improve outcomes in corneal transplantation. To date, there has been no standardized protocol published that outlines the optimal prophylactic and therapeutic approaches and, furthermore, the published controlled trials on this subject are limited. Likewise, no study has addressed how the level of antigen exposure varies between different types of keratoplasties. The aim of this paper is to provide a simple evidence-based protocol for the prevention and treatment of corneal graft rejection.摘要: 对于角膜移植术后的排斥反应进行有效的预防和治疗对与改善角膜移植术的预后至关重要。到目前为止, 还未有针对角膜移植排斥的最佳预防与治疗方法的标准方案, 另外, 已发表的对照试验例数有限。更没有研究证实不同类型的角膜移植术后抗原暴露程度如何变化。本文旨在提供一个简单的、具有循证依据的针对角膜移植术后角膜移植排斥反应的临床方案。预防和治疗角膜移植排斥的文献回顾与建议方案摘要: 对于角膜移植术后的排斥反应进行有效的预防和治疗对与改善角膜移植术的预后至关重要。到目前为止,还未有针对角膜移植排斥的最佳预防与治疗方法的标准方案,另外,已发表的对照试验例数有限。更没有研究证实不同类型的角膜移植术后抗原暴露程度如何变化。本文旨在提供一个简单的、具有循证依据的针对角膜移植术后角膜移植排斥反应的临床方案。.

Purpose To report the results of osteo-odonto-keratoprosthesis (OOKP) surgery in patients who sustained severe chemical and thermal injuries. Methods This is a noncomparative retrospective case series of 14 patients who underwent OOKP surgery between 2001 and 2016 at the Sussex Eye Hospital, Brighton, UK, because of severe chemical and thermal injuries RESULTS:: OOKP surgery was performed in 14 eyes of 14 patients. Eight patients (57%) sustained thermal injuries and 6 patients (43%) chemical injuries. Every eye had previously undergone adnexal or ocular surgery, including 2 cases that underwent synthetic keratoprosthesis implantation. One case had choroidal hemorrhage during stage 2. Laminar retention was observed in 11 cases (85%) at the end of the study. The Kaplan-Meier curve showed a probability of 81% of laminar retention at 5 years and a decrease at 15 years to 61%. Functional visual success was observed in only 7 patients (50%) because of end-stage glaucomatous optic neuropathy in 4 cases and macular scar in 1 case. Two cases developed endophthalmitis. Two cases required removal of laminae, one because of endophthalmitis, bone resorption and aqueous leak and the other because of development of a retroprosthetic membrane. Glaucoma was the most frequent complication (79%) and required surgical intervention with tube shunts in 5 cases. Six cases (43%) required buccal mucosal repair, which included two cases that developed endophthalmitis. Conclusions Anatomic success was achieved in 11 of 13 cases in this series of OOKP surgery after severe chemical and thermal trauma; 8 of these cases had at least 5 years of follow-up and thus qualified as long-term.

Background The aim of this study was to evaluate the surgical handling and clinical applicability of a specific 3D-printed membrane design fabricated using a gelatin, elastin and sodium hyaluronate blend for conjunctival reconstruction and compare it with amniotic membrane (AM), which is normally used in such surgeries. Methods 3D printing technique was employed to fabricate the membrane based on gradient design. Prior to printing, rheometry was employed to optimize the ink composition. The printed membranes were then fully characterized in terms of physical and mechanical properties. In vitro viability, proliferation and adhesion of human limbal epithelial cells were assessed using MTT assay and scanning electron microscopy (SEM), respectively. Prior to in vivo experiment, surgical handling of each membrane was evaluated by three surgeons. In vivo evaluation was conducted through implanting the gelatin-based membranes and AM on induced conjunctival defects in rabbits (n = 8). Clinical observations, including epithelialization, inflammation severity, scar tissue formation and presence of granulation tissue, were recorded from day 1 through day 28. Histological examination was performed on all enucleated eyes on day 28. In addition to H&E staining, specific stains including Periodic Acid Schiff staining, Masson's Trichrome staining and immuno-histochemical staining for α-SMA were further used to assess goblet cell proliferation, healed sub-epithelial stroma and scar tissue formation and the presence of myofibroblasts, respectively. Results Among all the examined compositions, a blend of 8% w/v gelatin, 2% w/v elastin and 0.5% w/v sodium hyaluronate was found to be appropriate for printing. The printed membranes had favorable optical characteristics (colorless and transparent), and the surgical handling was significantly easier compared to AM. Epithelial cells cultivated on the membranes indicated suitable viability and proliferation, and SEM images presented appropriate cell adhesion on the surface of the membranes. Clinical observations suggested similar epithelialization time (approximately 3 weeks) for both the membrane and AM grafted eyes but significantly lower levels of clinical inflammation in the membrane group from day 1 through day 28 (p = 0.01), which is a key advantage of using the printed membranes over the AM. Histological examination showed similar qualities in the healed epithelium in terms of cell morphology and cell layers. However, twice the density of goblet cells per 100 cells was observed in the gelatin-based membrane grafted group. Remnant of the degraded implant was seen in only 3 of the membranes, but in 7 of the AM grafted eyes. Inflammation and granulomatous reaction was significantly higher in sections containing the AM compared to membrane (p ≺ 0.01 and p = 0.01, respectively). α-SMA staining was more evident, but not significantly different from the gelatin-based membrane, for the AM group (p = 0.25). Conclusion The designed gelatin-based membrane offers the necessary physical and mechanical characteristics needed for successful ocular surface/conjunctival defect construction and may be considered a promising alternative to AM due to a more predictable degradation pattern, higher goblet cell density on the healed epithelium, less inflammation and reduced scar tissue formation.

Purpose To evaluate the efficacy of topical tacrolimus 0.05% as adjuvant therapy to corticosteroids in the treatment of acute endothelial rejection of a penetrating keratoplasty (PKP) graft. Methods Patients with the clinical diagnosis of acute endothelial rejection of a PKP graft were randomized into 2 groups-group 1: receiving topical tacrolimus 0.05% as adjuvant therapy to corticosteroid treatment and group 2: receiving only corticosteroid treatment. Main outcome measures were rejection reversal, time to rejection reversal, and recurrence of rejection. Results Thirty-one eyes of 31 patients (17 and 14 eyes in group 1 and 2, respectively) were included in the study. The rejection episode completely resolved in 88.2% of patients in group 1 and 85.7% of patients in group 2 [hazard ratio = 0.60, 95% confidence interval (CI) = 0.28-1.29, P = 0.191]. After adjusting for preoperative factors using the inverse-probability weighting method, the time to resolution of rejection was significantly shorter in group 1 than group 2 (average treatment effect = 16, 95% CI, 3.7-28.7, P = 0.013). The recurrence rate of rejection was significantly higher in group 2 (39.7, 95% CI, 12.8-92.6 per 1000 months of follow-up) than in group 1 (3.6, 95% CI, 0.05-19.9 likewise); risk ratio: 11.1, 95% CI, 1.3-95.0, P = 0.028. Conclusions Topical tacrolimus 0.05% as an adjunct to steroids can hasten the resolution of endothelial rejection of a PKP graft and potentially decreases the recurrence of rejection. However, it may not improve rejection reversal success.

Pterygium excision is probably the most common ocular surface procedure performed worldwide. These patients almost always have some degree of tear film of insufficiency and meibomian gland dysfunction highlighting the need for comprehensive management of the ocular surface disease. Inflammation clearly plays a central role both in the initial development as well as recurrence of pterygium. The cases presented by these highly experienced surgeons highlight strategies that can maximize the visual and cosmetic outcome of pterygium surgery while minimizing the risk of complications.

Purpose: To evaluate the sensitivity of photoscreener Plusoptix S08 in screening strabismus.Methods: Eighty-three consecutive patients were examined by a single expert to determine the type and amount of the deviation. Then photoscreening was done for all the patients via Plusoptix S08 photoscreener (Plusoptix GmbH, Nuremberg, Germany) on the same day, using the default software for referring the patients.Results: The age range was between 6 months and 40 years. The overall sensitivity of the device to detect strabismus is 70%; it was 25% for exophoria, 67% for esotropia, 73% for exotropia, and 89% in patients who had mixed strabismus. Regarding degree of deviation, sensitivity was 46% in deviations less than 30 prism diopters (PD) and rises while the degree of deviation increases.Conclusions: Our research shows that Plusoptix should not be used solely in evaluating strabismus because its sensitivity decreases significantly specially in esotropic patients with less than 30 PD deviations.

To evaluate anterior segment optical coherence tomography (AS-OCT) in the preoperative simulation of postoperative iris-fixated phakic intraocular lens (pIOL) position in the anterior chamber.Farabi Eye Research Center, Department of Ophthalmology, Tehran University of Medical Sciences, Tehran, Iran.Case series.Using AS-OCT, the pIOL position was simulated preoperatively in 2 ways and compared with the actual postoperative pIOL position. For preoperative evaluations, the simulator was placed on the posterior pigmented epithelium of the iris. Then, the simulation was performed with the simulator placed in the middle of the iris tissue. The following distances were measured: from the center of the pIOL to the endothelium, from the edge of the pIOL to the endothelium, and from the posterior surface of the pIOL to the crystalline lens.The study examined 26 eyes (16 patients). Although all distances in both simulation methods (except the lens vault in the first method of simulation) were highly correlated (all P.009), only the results with the simulator placed in the middle of the iris tissue were not statistically different from the corresponding postoperative measurements (P=.209 and P=.564 for distance from endothelium to the center and the pIOL edge, respectively).Using the pIOL template of the AS-OCT system for preoperative simulation of iris-fixated pIOLs improved the criteria for patient selection for implantation of these pIOLs. The simulator should be placed in the middle of the iris tissue for preoperative simulation.No author has a financial or proprietary interest in any material or method mentioned.

To evaluate the accuracy and applicability of Plusoptix photoscreener in screening pre-verbal children at risk of amblyopia.In this cross-sectional population-based study 996 children aged 6-36 months were screened with the Plusoptix. The children underwent complete examinations that included a manual cycloplegic retinoscopy, slit lamp examination, cover test, the Hirschberg test and an assessment of fixation pattern. In addition, the prevalence of amblyogenic risk factors was estimated, the Plusopix measurements were compared with cycloplegic retinoscopy, and the referral criteria were modified to improve the accuracy of the device.Amblyogenic hyperopia+3.50 D, myopia-3.00 D, astigmatism1.50 D in the orthogonal meridian or1.00 D in the oblique meridian, or anisometropia1.50 D was detected in 4.7%, 0.0%, 12.3% and 0.5% of the samples, respectively. The average difference between retinoscopy and photorefraction for spherical equivalence was -0.16 ± 1.0 D (p0.05). Testability was 98.1% for the Plusoptix. The Plusoptix vision screener referred 47.8% of these children for sensitivity, specificity, positive predictive value and false-negative rates of 100%, 38.7%, 19% and 100%, respectively. These same measurements with the modified referral criteria (hyperopia ≥ 2.00 D in children under 12 months and astigmatism ≥ 1.25 D) were 93.6%, 51.2%, 21.7% and 98.2%.The Plusoptix is a useful objective screening instrument, but still has low specificity for detecting amblyopia risk factors in the paediatric population.

PURPOSE To evaluate the clinical results of a mechanical keratectomy with mitomycin C (MMC) and extended wear contact lens (EWCL) for the treatment of corneal haze after photorefractive keratectomy (PRK) of high myopia. SETTING Eye Research Center, Khatam-al-Anbia Eye Hospital, Mashhad University of Medical Sciences, Iran. METHODS : In a retrospective interventional case series, we enrolled 15 eyes of 9 patients who previously underwent PRK for high myopia and developed corneal haze and regression. Mechanical removal of corneal haze was done by using a surgical blade number 15. Then, MMC (0.02%) was used for 2 minutes. An EWCL was applied for 1 month. The main outcome measures were uncorrected visual acuity, best-corrected visual acuity, spherical equivalent (SE), and corneal haze grade. All patients were followed for a minimum of 6 months. RESULTS The mean age of the patients was 25.66 ± 7.03 years; 7 patients were men and 2 patients were women. The mean best-corrected visual acuity before superficial keratectomy was 20/80 (range, 20/200-20/50) and improved to 20/20 after treatment (P < 0.05). Thirteen eyes (86.6%) achieved an uncorrected visual acuity of at least 20/40. The mean preoperative SE was 3.91 ± 1.30, and the mean final postoperative SE was -0.85 ± 1.19 (P < 0.05). Eight eyes (53%) were within 1 diopter of emmetropia. Corneal haze in all patients declined to a trace haze or complete clearness. No recurrence occurred during the mean follow-up time of 12 months. CONCLUSIONS Superficial keratectomy with MMC and EWCLs is effective in reducing persistent and refractory corneal haze after PRK.

We describe a simple method for evaluating the adequacy of the capsule for implantation of a foldable intraocular lens (IOL) during phacoemulsification complicated by a posterior capsule tear. After cortical lens material clean-up and anterior vitrectomy (if required), 3 knots of 10-0 nylon are tied to the trailing haptic of the IOL using a 3/1/1 configuration. Then, the IOL is inserted into the sulcus. If it is unstable when the surgeon tries to deepen or shallow the anterior chamber, gently pulling the nylon thread will prevent posterior IOL dislocation. Two further attempts to implant the IOL in the other meridians of the capsule are made. The results of using this technique in 10 eyes of 10 patients are reported. Optic decentration occurred in 1 case (10%). No postoperative dislocation was observed, and no patient required surgery for IOL decentration during the follow-up.

PURPOSE: To evaluate the clinical outcomes of Artisan phakic intraocular lens (PIOL; Ophtec BV) implantation in patients with stable keratoconus. METHODS: In a prospective, nonrandomized case series, 14 Artisan PIOLs and 2 toric Artisan PIOLs were implanted in 13 patients (16 eyes) with stable keratoconus who had contact lens intolerance. Pre- and postoperative data were collected. RESULTS: Mean follow-up was 14.2±7.8 months. Preoperative uncorrected distance visual acuity (UDVA) was counting fingers in all patients. Mean final logMAR (Snellen equivalent) UDVA and corrected distance visual acuity (CDVA) were 0.15(20/28)±0.13 and 0.11(20/26)±0.10, respectively. The improvements in UDVA and CDVA were statistically significant ( P P CONCLUSIONS: Implantation of the Artisan PIOL is effective in improving visual acuity in patients with stable keratoconus. Long-term safety remains to be established as no postoperative endothelial cell counts were performed.

Purpose To determine the effect on postoperative outcomes of different sites for intrastromal corneal ring segment (ICRS) implantation in keratoconic eyes. Setting Eye Research Center of Mashhad University of Medical Sciences, Khatam-al-Anbia Eye Hospital, Mashhad, Iran. Design Case series study. Methods After a detailed ophthalmologic examination, pairs of 160-degree Ferrara ICRS were implanted in eyes with keratoconus. Patients were categorized into 2 groups depending on the axis of ICRS implantation as follows: vertical implantation, in which the axis of the radial incision was between 70 degrees and 110 degrees, and oblique implantation, in which the axis was outside the vertical range. An independent-samples t test was used to compare the postoperative refractive and visual outcomes in the 2 groups. Results This series included 48 eyes of 48 patients (28 men, 20 women) with a mean age of 26.65 years ± 6.8 (SD). The vertical implantation group comprised 23 patients and the oblique implantation group, 25 patients. There was no statistically significant difference in any preoperative parameter between the groups. The mean postoperative corrected distance visual acuity and astigmatism reduction were significantly better in the vertical group than in the oblique group (P Conclusion Although the improvements in refractive outcomes and visual acuity were significant in eyes with vertical or oblique astigmatism, simulated keratometry showed that patients with a vertical steep axis had more favorable results than those with an oblique steep axis. Financial Disclosure Neither author has a financial or proprietary interest in any material or method mentioned.

Purpose To compare 2 corneal biomechanical parameters—corneal hysteresis (CH) and corneal resistance factor (CRF)—before and after collagen crosslinking (CXL) for keratoconus. Setting Eye Research Center of Mashhad University of Medical Sciences, Khatam-al-Anbia Eye Hospital, Mashhad, and Department of Ophthalmology, Baqiyatallah University of Medical Science, Tehran, Iran. Design Case series study. Methods Topical riboflavin was applied to the deepithelialized cornea every 3 minutes for 30 minutes and every 5 minutes during ultraviolet-A irradiation of the cornea. Corneal hysteresis and CRF were measured by biomechanical waveform analysis (Ocular Response Analyzer) before and 6 months after CXL. The values were compared using the paired Student t test. Results The study comprised 51 patients (56 eyes). The mean age of the patients was 23.27 years ± 6.3 (SD). Before CXL, the mean CH was 7.9 ± 1.5 mm Hg and the mean CRF was 7.3 ± 1.4 mm Hg. Six months after CXL, the mean values were 8.20 ± 1.5 mm Hg and 7.59 ± 1.5 mm Hg, respectively. The changes in CH and CRF were not statistically significant ( P >.05). The changes in central corneal thickness and Goldmann-correlated intraocular pressure (IOP) between preoperatively and postoperatively were not statistically significant, although the change in corneal-compensated IOP was ( P Conclusion Although previous in vitro studies found a change in corneal rigidity, this study found no significant change in CH or CHF measured by biomechanical waveform analysis. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

PURPOSE To describe a case of traumatic wound dehiscence after deep anterior lamellar keratoplasty. METHOD Observational case report. CASE REPORT A 31-year-old man who had undergone deep anterior lamellar keratoplasty using big-bubble technique for keratoconus 3 months earlier presented to emergency room after blunt trauma.On examination, visual acuity was counting fingers at 2 m. The corneal graft wound dehisced from 12 to 3 o'clock (90 degrees) with localized suture ruptures, but the anterior chamber was deep and the Seidel test was negative. Surprisingly, there was intact Descemet membrane prolapsed through the corneal wound gap. CONCLUSION This case indicates that intact Descemet membrane remaining after big-bubble technique might reduce the severity of ocular injury after traumatic wound dehiscence.

Purpose: To evaluate changes in crystalline lens densitometry following corneal cross-linking (CXL) in keratoconic patients. Methods: In a quasi-experimental study, three-dimensional lens densitometry was performed using the Pentacam Scheimpflug camera (Oculus Optikgerate GmbH, Wetzlar, Germany) at baseline and six months after CXL. Densitometry was performed in a fixed area of 2 inch × 1 inch of the anterior capsule and anterior lens cortex. The subject group included patients with progressive keratoconus who underwent CXL ( n = 40) and the control group was comprised of aged-matched patients with non-progressive keratoconus ( n = 36). Results: Mean age of the case and control groups was 25.8 ± 4.0 and 25.0 ± 4.1 years, respectively ( P = 0.392). Mean lens density in the CXL group was 6.68% ± 0.58% at baseline and 6.77% ± 0.53% at the last visit ( P = 0.352). Corresponding figures in the control group were 6.53% ± 0.27% and 6.39% ± 0.31%, respectively ( P = 0.213). There was no significant difference between the study groups at baseline or six months later ( P = 0.96). Conclusion: In this short term study with six months' follow-up, we observed no significant impact on lens density following exposure of the crystalline lens to ultraviolet A and riboflavin free radicals in the CXL procedure.

Recently, endothelial keratoplasty has been shown to offer a promising alternative to penetrating keratoplasty for the management of corneal endothelial failure. Melles et al 1 introduced a new technique for transplantation of Descemet membrane (DM) through a self-sealing incision, which they referred to as Descemet membrane endothelial keratoplasty (DMEK). They obtained donor material by stripping DM with fine forceps. This is a challenging and time-consuming procedure with inevitable endothelial cell loss and possibility of DM tear. Herein, we describe a new technique to prepare donor tissue for DMEK, the reverse big-bubble technique. A corneoscleral button was placed endothelial side up on a donor Barron punch and fixed by grasping the outer scleral edge. The endothelial layer was stained with trypan blue. A 27-gauge bevel-up needle attached …

Purpose: To evaluate the clinical features, and visual outcomes of sterile uveitis after iris-fixated phakic intraocular lens implantation (pIOLs) (Artisan-Artiflex® and Verisyse-Veriflex® ). Material and Methods: In this retrospective non-comparative case series, the medical records of 117 eyes implanted with Artisan-Artiflex® (Ophtec BV, Groningen, Netherlands) and Verisyse-Veriflex® (AMO, Santa Ana, CA) iris claw phakic IOLs were analyzed for postimplantation sterile uveitis. The mean age of the 87 patients included in the study was 27.2±7.4 years. Of these patients, 56 (64.3%) were men and 31 (35.6%) were women. Patient age, gender, IOL brand type, refractive error, optic diameter, unilateral vs bilateral implantation, and anterior chamber depth were analyzed. Features of uveitis, uncorrected and best corrected visual acuity (VA) at presentation and at follow-up visits were examined. The mean follow-up time was 14.6 months (range: 6-37 months). Results: Clinically significant uveitis was observed in 12 of 117 eyes (10.3%) in a total of ten patients. Of these ten patients, four (40%) were women and six (60%) were men, and the mean age was 25.1±5.3 years (range: 18-36 years). Among those with bilateral implantation, 6.9% of patients developed bilateral uveitis, while 13.8% (4 of the 29 implanted bilaterally) developed unilateral uveitis. Foldable pIOL implantation was the only variable associated with the development of uveitis (P=.03). Conclusion: Although the prognosis is usually benign, sterile uveitis occurred in 10.3% of patients after iris-fixated pIOL implantation. The implantation of a foldable pIOL was the only variable associated with sterile uveitis. Appropriate medical management can be effective treatment, without the need for pIOL replacement.

Air-assisted donor preparation for DMEK Venzano al. have described a technique of Descemet membrane air-bubble separation. We also use an air-assisted (reverse big bubble) technique to prepare Descemet membrane for Descemet membrane endothelial keratoplasty. In our method, a corneoscleral button is placed endothelial side up on a Barron donor punch and fixed by grasping the outer scleral edge with a 0.12 forceps. A 27-gauge bevel-up needle attached to a 2 mL syringe filled with air is inserted into the posterior stroma with the entry point located just outside Schwalbe line. The needle is advanced to the central cornea. Air is gently injected to make a big bubble, detaching Descemet membrane from the posterior stroma. Injecting into the endothelial side-up corneoscleral button allows us better visualization and makes the procedure more feasible, less instrument dependent, and less traumatic. Venzano et al. reported a high success rate of Descemet membrane detachment with their method. This high rate of success might be related to the older age (mean Z 78 years) of donors. In our experience, we found that air-assisted Descemet membrane dissection is more difficult in young patients (younger than 40 years) and attempts to make a complete detachment may lead to Descemet membrane rupture. In our first 10 cases, with a mean age of 32 years, an incomplete detachment (smaller than 8.0 mm diameter) occurred in 2 cases and Descemet membrane rupture occurred in 1 case. We now prefer older donors with higher endothelial cell counts for this technique.

Aim and Design: A retrospective, nonrandomized, single-center clinical study was designed to evaluate the outcomes of corneal collagen crosslinking (CXL) for progressive keratoconus in Iranian patients 12 months after CXL. Settings: This study was carried out at Navid Didegan Eye Center, a private clinic, Mashhad, Iran. Materials and Methods: Ninety-two eyes of 53 subjects with progressive keratoconus were evaluated in this study. All eyes completed 1-year follow-up. The outcome measures were uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BSCVA), sphere and cylinder refraction, keratometry, and corneal thickness. Comparison of baseline and 1-year postoperative data is reported in this study. The Wilcoxon signed-ranked and Student’s t-tests were used for statistical analyses. P < 0.05 was statistically significant. Results: The mean age was 21.5 ± 3.4 years (range, 16 -30 years). Thirty-one (58.5%) of the subjects were men and 22 (41.5%) were women. Mean baseline UCVA and BSCVA were 0.61 ± 0.31 and 0.06 ± 0.12 logarithm of minimal angle of resolution (logMAR), respectively. One year postoperatively UCVA was 0.31 ± 0.25 logMAR and BSCVA was 0.0 ± 0.01 logMAR. UCVA and BSCVA were statistically higher postoperatively (P < 0.001, both parameters). The mean astigmatism decreased by 0.78 ± 1.49 diopter (D) with significant variation during the follow-up period (P < 0.001). Mean baseline simulated keratometry (SIM K) was 46.94 ± 2.37 D and decreased to 46.0 ± 2.33 D on year postoperatively (P < 0.001). Conclusion: Corneal CXL seems to be efficient in stabilization of progressive keratoconus progression in Iranian patients at 1 year of followup.