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Purpose: To determine predictive factors of higher levels of best-corrected visual acuity (BCVA) in the long-term after primary Descemet's membrane endothelial keratoplasty (DMEK)., Methods: Retrospective, single-surgeon case series of 129 successful primary DMEK eyes without graft failure and with a minimum postoperative follow-up of 12 months. Mixed effect model for repeated measurements (MMRM) analysis was performed to determine recipient, donor, surgical and postoperative factors associated with BCVA ≤ 0.10 logMAR (≥ 20/25 Snellen)., Results: After primary DMEK, there was a statistically significant improvement in BCVA with a global reduction in logMAR BCVA (p < 0.00001). There was also a global tendency towards increasing proportion of eyes with BCVA ≤ 0.10 logMAR at all time points (p < 0.00001), from 1.6% before DMEK to 64.4% in eyes with more than 5 years of F-U. Absence of retinal disease was associated with a decrease of 0.10 logMAR in postoperative BCVA after primary DMEK, maintaining constant the rest of variables (p < 0.001). The variables age (OR 0.960), postoperative time (OR 1.083), preoperative BCVA ≥ 0.375 logMAR (OR 0.162) and indication for DMEK (OR 5.412) were included in the predictive MMRM model of BCVA ≤ 0.10 logMAR., Conclusion: Primary DMEK is associated with statistically and clinically significant improvement in BCVA that occur early in the postoperative period and are continuous over time. Eyes with retinal comorbidities have increased risk of worse postoperative BCVA after DMEK. Younger recipient age, Fuchs' dystrophy eyes and eyes with better preoperative BCVA are more likely to achieve postoperative BCVA ≤ 0.10 logMAR., Competing Interests: Declarations Conflict of interest The authors declare no conflict of interests. Research involving human participants This retrospective chart review study involving human participants was in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. This study was approved by an institutional review board (IRB)—Comisión de Ética e Investigación Médica del Instituto de Microcirugía Ocular—CEIm, study COD IMO 210324-174., (© 2024. The Author(s), under exclusive licence to Springer Nature B.V.)

Purpose: To report the demographic profile, clinical characteristics, risk factors and outcomes of graft rejection after DSEK., Methods: A total of 3073 eyes had DSEK between 2012 and 2019, of which 1710 eyes that had follow up of more than one year. Sixty-one eyes who had graft rejection during this period were studied., Results: Overall, incidence of graft rejection during the study period was 3.6% (61/1710 eyes) in those with follow up more than one year. The median age of patients was 58 (IQR 37.5-68) years. The indications were prior failed graft (34 eyes: 28 penetrating keratoplasty; 6 DSEK), post cataract surgery edema (12 eyes), Fuchs corneal endothelial dystrophy (6 eyes), corneal edema post inflammation (5 eyes) and iridocorneal endothelial syndrome (4 eyes). Of the 34 eyes with failed grafts, nine were post-rejection graft failures (two after endothelial keratoplasty and seven after penetrating keratoplasty), remaining 25 eyes were non-rejection graft failures. Ocular co-morbidities were noted in 41 eyes, of which secondary glaucoma was the most common (14 eyes). Clinical signs of graft rejection were diffuse edema, keratic precipitates and endothelial rejection line. Rejection episode occurred between 6-12 months after surgery in 20 (33%) eyes, 12-24 months in 15 (25%) eyes, 2-3 years in 12 (20%) eyes, and beyond 3 years in 14(23%) eyes. Graft clarity was restored in 55 (90%) eyes, which was complete in 41 (67%) eyes, partial in 14 (23%) eyes, and clarity was not restored in 6 (10%) eyes. The statistically significant risk factors for rejection were non-use of steroids (p value < 0.001), DSEK for failed graft (p value < 0.02) and DSEK for corneal edema post-inflammation (p value < 0.0014). DSEK for failed graft was a significant risk factor for graft failure after the rejection episode (p value < 0.05)., Conclusion: Graft rejection may occur as late as 5 years post-DSEK, emphasizing the need for long-term steroids instillation. Non-use of topical steroids, DSEK for failed graft and corneal edema post inflammation are risk factors for graft rejection. DSEK for failed graft was also seen as a risk factor for failure after the rejection episode The graft survival rate after the rejection episode was 90% at 6 months, 50% at 2 years and 10% at 5 years., Competing Interests: Declarations Conflict of interest The authors declare no competing interests., (© 2024. The Author(s), under exclusive licence to Springer Nature B.V.)

Purpose: To present ocular clinical, histological, systemic, and genetic findings of a patient with familial lecithin-cholesterol acyltransferase (LCAT) deficiency caused by a novel genetic variant of the LCAT gene associated with secondary corneal amyloidosis., Methods: Case report., Results: A 74-year-old woman presented with decreased visual acuity (VA), sensitivity to light, and progressive whitening of both corneas for approximately 20 years. The patient had undergone penetrating keratoplasty (PKP) on the right eye 6 years ago. Ophthalmologic examination revealed decreased VA in both eyes (OD: 0.05, OS: 0.3), and even further reduced glare VA (OD: 0.05, OS: 0.1), diffuse whitish corneal opacity involving the total thickness of the corneal stroma without crystalline deposits, and a marked peripheral diffuse arcus. Systemic examination revealed severely reduced plasma high-density lipoprotein cholesterol levels, target cells in blood smear, and chronic normochromic anemia. Clinically, LCAT deficiency was the most likely diagnosis. Further genetic analysis confirmed the diagnosis. The patient is homozygous for the novel variant c.943T>C (p.Trp315Arg) in the LCAT gene. Histologic examination of the cornea removed during the first keratoplasty revealed amyloid deposits. The cornea removed at the second keratoplasty had small vacuoles in the anterior stroma, indicating recurrence of lipid deposition., Conclusions: LCAT deficiency is a rare genetic disorder that can cause corneal opacities because of lipid deposition in the cornea. Systemic manifestations may help in the differential diagnosis to other diseases associated with severe high-density lipoprotein cholesterol reduction. Genetic analysis is employed to confirm the diagnosis. Some mutations in the LCAT gene seem to be associated with secondary corneal amyloidosis. Further investigation of this association is warranted. A recurrence of corneal opacity after PKP seems to occur mainly in the anterior corneal stroma., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

The Descemet membrane (DM) is the basement membrane of corneal endothelial cells, which are responsible for maintaining corneal transparency. DM detachment (DMD) can occur due to various reasons, with the most common etiology being post-surgical. Older age, blunt instruments, and faulty surgical technique predispose to the intraoperative or postoperative occurrence of DMD, and one should have a high index of suspicion for DMD in cases with unexplained or an atypical pattern of corneal edema after surgery. Prompt intervention for DMD management is imperative to effect early visual rehabilitation, decrease corneal morbidity, and avoid permanent damage leading to scarring of the cornea. Various classifications of DMD and management protocols have been described. Anterior-segment optical coherence tomography (AS-OCT) imaging is the most effective imaging to detect DMD and quantify its extent. Desmetopexy with air/gas is the initial treatment of choice and could be aided by suture fixation. Non-responsive cases might need endothelial keratoplasty., (Copyright © 2024 Copyright: © 2024 Indian Journal of Ophthalmology.)

Purpose: Corneal neurotization is an emerging technique that offers potential for visual rehabilitation in neurotrophic keratopathy. This study reports on a multicenter experience and outcomes for both direct and indirect methods of corneal neurotization., Methods: Retrospective case series. Sixteen patients with neurotrophic keratopathy who underwent corneal neurotization across 5 centers in Australia and Israel were identified for inclusion. Corneal neurotization was performed via direct neurotization from the ipsilateral or contralateral supraorbital/supratrochlear nerve or by the use of an interpositional sural nerve graft. Change in corneal sensitivity (measured in millimeters by the Cochet-Bonnet aesthesiometer), visual acuity, and corneal health., Results: Over a mean follow-up period of 31.3 months (range: 3 months-8 years), mean corneal sensitivity improved from 3.6 mm (range: 0-25 mm) to 25.3 mm (range: 0-57 mm). Visual acuity improved on average from 20/380 to 20/260. Twelve of 16 patients (75.0%) improved in at least 2 out of the 3 main outcome measures. Nine patients (56.3%) showed an improvement in visual acuity; 13 (81.3%) showed an improvement in average corneal sensitivity; and 11 (68.8%) showed an improvement in corneal health. There were no intraoperative or postoperative complications., Conclusions: Corneal neurotization is an emerging surgical treatment option for the management of neurotrophic keratopathy. With appropriate case selection, outcomes are favorable and complication rates are low, for a condition that is otherwise challenging to manage. Patients with severe neurotrophic keratopathy should be considered for this surgical treatment option., Competing Interests: The authors have no financial or conflicts of interest to disclose., (Copyright © 2024 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)

Purpose: To investigate whether neurotrophic keratopathy is present in limbal stem cell deficiency (LSCD), by measuring corneal sensation and characterizing corneal subbasal nerve plexus., Design: Prospective, cross-sectional, case-control comparative study., Methods: A total of 46 eyes with LSCD and 14 normal eyes were recruited from 2019 to 2022. Corneal sensation was measured using a Cochet-Bonnet esthesiometer, and subbasal nerve plexus was imaged using in vivo confocal microscopy (IVCM) at the central cornea and 4 limbal regions. Subbasal nerve density (SND, number of nerves/mm 2 ), subbasal nerve length (SNL, total length of nerves/mm 2 ) and subbasal nerve branch density (SNBD, number of branches/mm 2 ) were quantified. LSCD was graded to stage 1, 2, and 3 using a previously established staging method consisting of clinical scores, basal cell density, central corneal epithelial thickness, and SNL., Results: The mean (±SD) cornea sensation in the central cornea and limbus were 29.2 ± 21.5 and 33.6 ± 15.1 mm in the LSCD group and 57.6 ± 5.8 and 54.3 ± 4.7 mm in the control group, respectively (all P < .001). In sectoral LSCD, the corneal sensation in the affected regions (29.1 ± 17.6 mm) decreased significantly compared to the unaffected regions (41.4 ± 18.2 mm, P < .001). Central corneal SND, SNL, and SNBD were reduced by 84.6%, 82.6%, and 89.2%, respectively, in LSCD compared to controls (all P < 0.05). The central corneal sensation negatively correlated with the severity of LSCD (rho = -0.64, P < .0001) and positively correlated with SND, SNL, and SNBD (rho = 0.63, 0.66, and 0.56, respectively; all P < .001)., Conclusions: Corneal sensation was reduced in eyes with LSCD. The degree of corneal sensation reduction positively correlated with the severity of LSCD. This finding demonstrated the coexistence of neurotropic keratopathy in LSCD., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Objectives: To evaluate the clinical characteristics and treatment strategies of limbal stem cell deficiency (LSCD) patients managed with medical therapy., Materials and Methods: The study included 29 eyes of 21 patients with LSCD who were managed medically at Ege University Faculty of Medicine, Department of Ophthalmology between May 2013 and May 2023. LSCD stages before and after medical treatment were recorded according to the LSCD staging system published by the International LSCD Working Group. The medical records of patients showing improvement in LSCD stage with medical treatment without surgical intervention were evaluated., Results: The mean age was 35.5±23.8 years (range, 5-71 years) with a male-to-female ratio of 6:15. The primary etiology of LSCD was ocular rosacea in 12 patients (57.1%), marginal keratitis in the setting of blepharitis in 8 patients (38.1%), and topical medication toxicity in 1 patient (4.8%). The mean baseline best corrected visual acuity (BCVA) was 0.25±0.26 logarithm of the minimum angle of resolution (logMAR) (range, 0-1 logMAR). Pre-treatment LSCD stage was stage 1A in 5 eyes (17.2%), stage 1B in 12 eyes (41.4%), stage 1C in 4 eyes (13.8%), stage 2A in 4 eyes (13.8%), and stage 2B in 4 eyes (13.8%). Complete regression of LSCD was achieved in 6 eyes (20.7%) with medical treatment addressing the primary etiology. In the remaining eyes, after medical treatment, the severity of LSCD decreased below the surgical threshold, which is considered stage 2B. The mean final BCVA was 0.07±0.1 logMAR (range, 0-0.4 logMAR)., Conclusion: This study highlights that LSCD can be completely or partially reversible with appropriate management, especially in cases with underlying limbal niche dysfunction, where inflammation plays a significant role. Although limbal stem cell transplantation is considered the main treatment approach for LSCD, localized and early-stage LSCD can be effectively managed medically without the need for surgical intervention., Competing Interests: Conflict of Interest: Sait Eğrilmez, MD, is an Associate Editor of the Turkish Journal of Ophthalmology. He was not involved in the peer review of this article and had no access to information regarding its peer review. The other authors have no disclosures., (©Copyright 2024 by the Turkish Ophthalmological Association / Turkish Journal of Ophthalmology published by Galenos Publishing House.)

This study aimed to comprehensively explore the intricacies of corneal neurotization (CN) and the nuanced factors that set it apart from routine clinical practice, exerting a substantial influence on its success. A symbiotic relationship is evident between corneal innervation and ocular surface health. The loss of corneal innervation results in a potentially challenging corneal condition known as neurotrophic keratopathy (NK). The majority of treatments are primarily focused on preventing epithelial breakdown rather than addressing the underlying pathogenesis. Consequently, to address the impaired corneal sensation (underlying etiology), a novel surgical approach has emerged, namely CN, which involves transferring healthy sensory nerve axons to the affected cornea. This review offers valuable insights into the existing body of supporting evidence for CN, meticulously examining clinical studies, case reports, and experimental findings. The aim is to enhance our understanding of the effectiveness and potential outcomes associated with this innovative surgical technique. The exploration of innovative therapeutic avenues holds promise for revolutionizing the management of NK, offering a potentially permanent solution to a condition once deemed incurable and severely debilitating., (Copyright © 2024 Copyright: © 2024 Indian Journal of Ophthalmology.)

Purpose: Corneal subbasal nerve parameters have been previously reported using 2-dimensional scans of in vivo laser scanning confocal microscopy (IVCM) in eyes with limbal stem cell deficiency (LSCD). This study aims to develop and validate a method to better quantify corneal subbasal nerve parameters and changes from reconstructed 3-dimensional (3D) images., Methods: IVCM volume scans from 73 eyes with various degrees of LSCD (mild/moderate/severe) confirmed by multimodal anterior segment imaging including IVCM and 20 control subjects were included. Using ImageJ, the scans were manually aligned and compiled to generate a 3D reconstruction. Using filament-tracing semiautomated software (Imaris), subbasal nerve density (SND), corneal nerve fiber length, long nerves (>200 μm), and branch points were quantified and correlated with other biomarkers of LSCD., Results: 3D SND decreased in eyes with LSCD when compared with control subjects. The decrease was significant for moderate and severe LSCD ( P < 0.01). 3D SND was reduced by 3.7% in mild LSCD, 32.4% in moderate LSCD, and 96.5% in severe LSCD. The number of long nerves and points of branching correlated with the severity of LSCD ( P < 0.0001) and with declining SND (R 2 = 0.66 and 0.67, respectively). When compared with 2-dimensional scans, 3D reconstructions yielded significant increases of SND and branch points in all conditions except severe LSCD. 3D analysis showed a 46% increase in long nerves only in mild LSCD ( P < 0.01)., Conclusions: This proof-of-concept study validates the use of 3D reconstruction to better characterize the corneal subbasal nerve in eyes with LSCD. In the future, this concept could be used with machine learning to automate the measurements., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To present a case series of patients with corneal scars who were successfully fitted with mini scleral contact lenses (mSCL)., Methods: Case series study., Results: Six eyes of six patients with corneal scars were fitted with mSCLs. All scars were situated in the visual axis within the scotopic pupillary zone. The sizes of the scars varied, with the smallest being confined to a central corneal area (case 5) and the largest covering the entire visual axis (case 2). In addition to compromising corneal transparency, these scars also induced significant corneal irregularities, especially in cases 1, 3, and 4. The average corrected distance visual acuity (CDVA) with spectacles was 20/80, with a range of 20/200 to 20/40. With the use of mSCLs, CDVA improved to an average of 20/25, ranging from 20/40 to 20/16. The mean visual acuity improvement observed was five optotype lines, with a range of 3 to 7 lines., Conclusion: Corneas with scars often exhibit increased higher-order aberrations (HOA), and affected patients not only experience reduced vision but also suffer from seriously reduced optical quality and optical phenomena such as photophobia. Utilizing mSCLs in such individuals can significantly enhance visual acuity and improve optical side effects resulting from corneal opacity and irregularity., (Copyright © 2024 Elsevier Masson SAS. All rights reserved.)

Objective: To assess the efficacy and safety of topical 0.5% 5-Fluorouracil (5-FU) as a primary therapy of ocular surface squamous neoplasia (OSSN)., Design: Retrospective study., Participants: Patients with clinically suspected OSSN referred to a Brazilian tertiary health center between October 2015 and December 2022., Methods: After diagnostic confirmation of OSSN with exfoliative cytology, 0.5% 5-FU was administered topically 4 times daily for 2 weeks followed by a pause of 2 weeks., Results: A total of 54 patients were included in this study, 32 males (59.3%), mean age of 62.9 years old. Complete resolution of OSSN was achieved in 70.4%. The median number of cycles was 2 (range 1-5). Side effects were reported in 35.2%, which included eyelid erythema, conjunctival hyperemia, and punctal stenosis. None of the patients stopped treatment due to adverse effects. Patients who had partial response to 0.5% 5-FU had complementary treatment with surgery, Mitomycin-C and/or Interferon ⍺2b. Overall recurrence was 14.8%. Median follow-up was 14 months (range 2-92 months). In a multivariate Cox regression analysis, the risk of relapse was 84% lower in patients who had complete response to 0.5% 5-FU (p = 0.018)., Conclusion: Topical 0.5% 5-FU may be considered a safe and effective primary therapy for OSSN, with a low rate of side effects., (Copyright © 2024 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved.)

Background: To evaluate the efficacy and safety of trans-epithelial phototherapeutic keratectomy (TE-PTK) as a treatment for recurrent corneal erosion syndrome (RCES) in patients with symptoms refractory to conventional treatments., Methods: All patients who received TE-PTK treatment for RCES had failed 3 or more conventional treatments and were reviewed, and if met criteria, approved by healthcare workers of the British Columbia public health authority (Medical Services Plan (MSP). A retrospective chart review and telephone survey were conducted at the Pacific Laser Eye Centre (PLEC). Exclusion criteria were ocular co-morbidities potentially affecting treatment efficacy., Results: This study included 593 eyes of 555 patients (46.2% male; 50.9 ± 14.2 years old) who underwent TE-PTK. The leading identified causes of RCES were trauma (45.7%) and anterior basement membrane dystrophy (44.2%). The most common pre-PTK interventions were ocular lubricants (90.9%), hypertonic solutions (77.9%), and bandage contact lenses (50.9%). Thirty-six eyes had undergone surgical interventions such as stromal puncture, epithelial debridement, or diamond burr polishing. Post-PTK, 78% of patients did not require any subsequent therapies and 20% required ongoing drops. Six patients (1.1%) reported no symptom improvement and required repeat TE-PTK for ongoing RCES symptoms after initial TE-PTK. All 6 eyes were successfully retreated with TE-PTK (average time to retreatment was 11.3 ± 14.9 months). There was no significant difference in best corrected visual acuity pre- vs. post-operatively. The mean post-operative follow-up was 60.5 months (range: 5-127 months)., Conclusion: TE-PTK has a good efficacy and safety profile for treatment-resistant RCES. The third-party public health-reviewed nature of this study, the low recurrence rate of RCES, and the low PTK retreatment rate suggest that TE-PTK might be considered for wider use in the management of RCES., (© 2024. The Author(s).)

Purpose: The aim of this study was to compare clinical characteristics and high-resolution optical coherence tomography (HR-OCT) findings between corneal ocular surface squamous neoplasia (OSSN) and corneal pannus., Methods: Retrospective study of 9 individuals, 3 with lesions histologically confirmed to be OSSN, 3 with lesions histologically confirmed to be pannus, 1 with lesions histologically confirmed to be OSSN followed by pannus, and 2 with long-standing, nonchanging lesions clinically diagnosed as pannus. All individuals presented to the Miami Veterans Affairs Medical Center eye clinic or Bascom Palmer Eye Institute between 2015 and 2023. Clinical characteristics and HR-OCT findings were evaluated and compared., Results: Mean age of the population was 72.8 ± 5.1 years, 100% self-identified as male, 100% as White, and 11.1% as Hispanic. Clinically, all lesions appeared as whitish, opalescent, variably vascularized opacities extending from the limbus. None of the OSSN cases had vessels that extended to the border, whereas 4 cases of pannus (67%) had at least 1 vessel that reached the border. On HR-OCT, epithelial hyperreflectivity was observed in all cases of OSSN and pannus. Epithelial thickening was observed in all cases of OSSN, but in none of the cases of pannus. An important distinction between the 2 groups was the transition between normal and abnormal epithelium. All cases of OSSN had a vertical transition, whereas all cases of pannus had an angled transition., Conclusions: Corneal OSSN and corneal pannus can both present with clinical findings of an opalescent lesion and may have overlapping findings on HR-OCT. Although both entities may show epithelial hyperreflectivity on HR-OCT, OSSN demonstrates an abrupt transition at a vertical, 90 degrees angle perpendicular to the Bowman layer, whereas pannus appears as an angled transition around 45 degrees. Therefore, the angle of transition between normal and abnormal epithelium can be useful in distinguishing between the 2 entities., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Dye-based angiography is the main imaging modality in evaluating the vasculature of the eye. Although most commonly used to assess retinal vasculature, it can also delineate normal and abnormal blood vessels in the anterior segment diseases-but is limited due to its invasive, time-consuming methods. Thus, anterior segment optical coherence tomography angiography (AS-OCTA) is a useful non-invasive modality capable of producing high-resolution images to evaluate the cornea and ocular surface vasculature. AS-OCTA has demonstrated the potential to detect and delineate blood vessels in the anterior segment with quality images comparable to dye-based angiography. AS-OCTA has a diverse range of applications for the cornea and ocular surface, such as objective assessment of corneal neovascularization and response to various treatments; diagnosis and evaluation of ocular surface squamous neoplasia; and evaluation of ocular surface disease including limbal stem cell deficiency and ischemia. Our review aims to summarize the new developments and clinical applications of AS-OCTA for the cornea and ocular surface.

Aim: To develop an artificial intelligence (AI) algorithm that diagnoses cataracts/corneal diseases from multiple conditions using smartphone images., Methods: This study included 6442 images that were captured using a slit-lamp microscope (6106 images) and smartphone (336 images). An AI algorithm was developed based on slit-lamp images to differentiate 36 major diseases (cataracts and corneal diseases) into 9 categories. To validate the AI model, smartphone images were used for the testing dataset. We evaluated AI performance that included sensitivity, specificity and receiver operating characteristic (ROC) curve for the diagnosis and triage of the diseases., Results: The AI algorithm achieved an area under the ROC curve of 0.998 (95% CI, 0.992 to 0.999) for normal eyes, 0.986 (95% CI, 0.978 to 0.997) for infectious keratitis, 0.960 (95% CI, 0.925 to 0.994) for immunological keratitis, 0.987 (95% CI, 0.978 to 0.996) for cornea scars, 0.997 (95% CI, 0.992 to 1.000) for ocular surface tumours, 0.993 (95% CI, 0.984 to 1.000) for corneal deposits, 1.000 (95% CI, 1.000 to 1.000) for acute angle-closure glaucoma, 0.992 (95% CI, 0.985 to 0.999) for cataracts and 0.993 (95% CI, 0.985 to 1.000) for bullous keratopathy. The triage of referral suggestion using the smartphone images exhibited high performance, in which the sensitivity and specificity were 1.00 (95% CI, 0.478 to 1.00) and 1.00 (95% CI, 0.976 to 1.000) for 'urgent', 0.867 (95% CI, 0.683 to 0.962) and 1.00 (95% CI, 0.971 to 1.000) for 'semi-urgent', 0.853 (95% CI, 0.689 to 0.950) and 0.983 (95% CI, 0.942 to 0.998) for 'routine' and 1.00 (95% CI, 0.958 to 1.00) and 0.896 (95% CI, 0.797 to 0.957) for 'observation', respectively., Conclusions: The AI system achieved promising performance in the diagnosis of cataracts and corneal diseases., Competing Interests: Competing interests: TY: Grants (Novartis Pharma); honoraria for lectures (Alcon Japan, HOYA, Novartis Pharma, AMO Japan, Santen Pharmaceuticals, Senju Pharmaceutical, Johnson & Johnson), MM: Grants (Novartis Pharma); honoraria for lectures (Bayer Yakuhin, Kowa Pharmaceutical, Alcon Japan, HOYA, Novartis Pharma, AMO Japan, Santen Pharmaceutical, Senju Pharmaceutical, Johnson & Johnson K.K., Japan Ophthalmic Instruments Association). MA: Grants (Novartis, Santen), honoraria for lectures (Novartis, Takeda, Senju, Chugai, Kowa), Support for attending meetings and travel (Wakamoto, Novartis), Endowed (NIDEK)., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: To report the demographic profile, clinical presentation, and management outcomes of ocular surface squamous neoplasia (OSSN) treated with primary topical chemotherapy in a limited resource secondary eye care facility in rural parts of South India., Methods: Retrospective interventional study of 38 eyes of 37 patients with OSSN treated with topical 1% 5-Fluorouracil (5FU), over a period of two years., Results: The median age at presentation with OSSN was 44 years (mean, 46 years; range 13 to 74 years). Majority (76%) were males. The most common morphological variant was placoid OSSN (18, 47%). Limbus was the most common epicenter (31, 82%). Corneal OSSN was the most initially misdiagnosed variant (n = 3). Of the 38 eyes receiving one week on and 3-weeks off cycles of 5FU regimen, complete tumor resolution was achieved in 36 (95%) eyes. The median number of topical 5FU cycles for tumor resolution was 2 (mean, 2; range, 1 to 4). Over a median follow-up period of 5 months (mean, 6 months; range, 1 to 27 months), tumor recurrence was noted in 3 eyes (8%), of which one case had xeroderma pigmentosum with bilateral multifocal recurrence. Complication rate was 5% (n = 2), which included transient conjunctival hyperemia (n = 1), and bacterial keratitis (n = 1) which resolved with fortified antibiotics., Conclusion: Primary chemotherapy with topical 1% 5FU is a safe and effective management modality for OSSN at limited resource settings in rural India., (© 2024. The Author(s).)

The authors report the surgical management and outcomes of neurotrophic keratopathy in two patients with Stüve-Weidemann syndrome who underwent single-stage bilateral corneal neurotization. Both patients experienced improvement in corneal sensation based on Cochet-Bonnet aesthesiometry measurements or cotton tip testing in addition to clinical improvement in ocular surface health. [ J Pediatr Ophthalmol Strabismus . 2024;61(5):e54-e58.] .

Purpose: To determine if early central corneal thickness (CCT) and best-corrected visual acuity (BCVA) changes indicate graft detachment after uncomplicated Descemet membrane endothelial keratoplasty (DMEK)., Methods: In this analysis of our prospectively collected ADDA registry data ( https://drks.de/search/de/trial/DRKS00027180 ), 45 pseudophakic eyes underwent DMEK surgery at the Department of Ophthalmology, RWTH Aachen University. Anterior segment optical coherence tomography (AS-OCT), the presence of stromal ripples on the posterior corneal surface, and BCVA measurements were assessed prior to, 1 day, 1 week, 1 month, and 6 months after surgery., Results: Eyes were categorized into three groups: no graft detachment (group 1) (20/45; 44.4%), < 1/3 graft detachment (group 2) (14/45; 31.1%), ≥ 1/3 graft detachment followed by rebubbling (group 3) (11/45; 24.4%). Eyes in group 3 had a greater CCT prior to (746.8 ± 95.8 µm vs. 665.0 ± 74.4 µm, P = 0.041), and 1 week (666.8 ± 119.5 µm vs. 556.5 ± 56.8 µm, P = 0.001) after DMEK compared to group 1. By 1 month, CCT in all groups aligned. Comparing prior to and 1 week after DMEK, none of the eyes in group 1 had an increase in CCT, while the CCT increased in 25.0% of eyes in group 2 and 22.2% in group 3. In group 1, 90.0% had a CCT of < 600 µm 1 week after DMEK, compared to only 50.0% in group 2 and 36.4% in group 3. In group 1, 90.0% (18/20) had an improved BCVA 1 week after DMEK, while in groups 2 and 3, 86.7% (12/14) and 18.2% (2/11) improved, respectively. One patient in group 3 showed posterior stromal ripples 1 day and 1 week after DMEK., Conclusion: If 1 week after uncomplicated DMEK CCT is < 600 µm and has decreased from before surgery, BCVA has improved, and there are no posterior stromal ripples, a graft detachment ≥ 1/3 and the need for rebubbling are very unlikely. In all other cases, meticulous slit-lamp and OCT inspection of the peripheral graft for detachments should be advised., (© 2024. The Author(s).)

Neurotrophic keratopathy is an uncommon degenerative corneal disorder characterized by compromised corneal sensory innervation resulting in the formation of epithelial defects and nonhealing corneal ulcers. Various treatment modalities are available to stabilize disease progression, improve patient well-being, and prevent vision loss. For eligible patients, medical and surgical reinnervation have emerged as pioneering therapies, holding promise for better management. We present a comprehensive review of the disorder, providing an update relevant to ophthalmologists on pathogenesis, diagnosis, treatment options, and novel therapies targeting pathophysiological pathways., Competing Interests: Declaration of Competing Interest None., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Purpose: This study aimed to investigate the long-term effects of COVID-19 on corneal endothelial cell morphology in patients with ocular symptoms to assess possible corneal involvement in patients who recovered., Methods: The COVID-19 group included patients diagnosed and treated at Istanbul University Cerrahpasa Medical Faculty with confirmed SARS-CoV-2 infection and ocular irritation symptoms. The control group was comprised of age- and sex-matched individuals. The controls had no ocular pathologies. Noncontact specular microscopy (Konan Cell Check SL, Hyogo, Japan) was performed using the center method after 156 ± 16 days of COVID-19 diagnosis. Parameters such as endothelial cell density (ECD), hexagonality (HEX), coefficient of variation, and central corneal thickness were analyzed., Results: Specular microscopy results of 54 COVID-19 patients with ocular irritation symptoms and 72 controls were evaluated. Ocular symptoms in COVID-19 patients included conjunctival hyperemia, foreign body sensation, tearing, ocular secretion, and chemosis. Mean (±SD) ECD was 2770 ± 31 (cells/mm 2 ) in the COVID-19 group and 2897 ± 26 in the control group, and mean (±SD) HEX was 46.52 ± 6.38 in the COVID-19 group and 58.22 ± 13.94 in the control group. COVID-19 patients exhibited significantly lower endothelial ECD and HEX levels than controls ( P = 0.003 and P < 0.001, respectively). Coefficient of variation and central corneal thickness analyses did not reach statistical significance., Conclusions: COVID-19 can cause long-term alterations in the corneal endothelial cells, leading to decreased ECD and HEX. Future research should focus on the long-term implications of COVID-19 on the corneal health and visual outcomes., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To report a rare case of atopic keratoconjunctivitis (AKC) presenting with bilateral corneal panni associated with limbal inclusion cysts in the left eye., Materials & Methods: Retrospective case report., Results: A 19-year-old female with AKC presented with bilateral corneal panni and limbal inclusion cysts in the left eye. Anterior segment swept-source optical coherence tomography showed bilateral hyperreflective epicorneal membrane and a lobulated cystic lesion in the left eye. Ultrasound biomicroscopy demonstrated a dense membrane overriding the cornea in both eyes and hyporeflective spaces separated by medium reflective septa in the cyst. The patient underwent excision of the limbal inclusion cyst and pannus in the left eye. Histopathological examination revealed subepithelial cystic lesion surrounded by non-keratinizing epithelium; areas of acanthosis, hyperkeratosis, parakeratosis, and hyperplasia in the epithelium of the pannus; as well as inflammation, fibrosis, and increase in vascularization in the stroma., Conclusion: To our knowledge, this is the first case of corneal pannus associated with limbal inclusion cysts in AKC. Surgical excision was done to establish the diagnosis as well as to improve vision in our case.

Importance: Infectious conjunctivitis can lead to corneal involvement and result in ocular morbidity. The identification of biomarkers associated with corneal involvement has the potential to improve patient care., Objective: To identify biomarkers in patients with acute infectious conjunctivitis., Design, Setting, and Participants: This cross-sectional study took place from December 2016 to March 2024. Analyses were performed in 3 phases. First, logistic regression and machine learning algorithms were used to predict the probability of demonstrating corneal involvement in patients with presumed infectious conjunctivitis. Second, quantitative reverse transcription polymerase chain reaction (RT-qPCR) was used to confirm the most important biomarker gene identified by the algorithm. Third, the biomarker gene was validated in prospectively collected conjunctival samples of adult patients from 3 outpatient centers in Thailand and 1 in India. Patients with signs and symptoms of infectious conjunctivitis and onset within less than 14 days were eligible. Exclusion criteria were the inability to consent, presumed toxicity, or allergic conjunctivitis., Exposures: Acute infectious conjunctivitis., Main Outcomes and Measures: The identification and validation of ocular surface gene expression associated with corneal findings on slitlamp examination., Results: Thirteen genes exhibited a 1.5-log2 fold change in expression in patients with corneal involvement compared to patients without corneal involvement. Using the 13 genes to train and cross validate, logistic regression produced the highest mean area under the receiver operating characteristic curve (AUROC; 0.85; 95% CI, 0.84-0.86) for corneal involvement. The removal of apolipoprotein E (APOE) from the gene ensemble led to a decline in predictive performance of the logistic regression classifier (from mean AUROC 0.85 [95% CI, 0.84-0.86] to 0.74 [95% CI, 0.73-0.75]; adjusted P = .001 [Tukey test]). Orthogonal testing of APOE expression level with RT-qPCR showed that APOE expression was higher in patients with corneal involvement compared to patients without (median [IQR], 0.23 [0.04-0.47] vs 0.04 [0.02-0.06]; P = .004 [Mann-Whitney U test]). Using a Youden index of 0.23 Δ threshold cycle, APOE had a sensitivity of 56% (95% CI, 33-77) and a specificity of 88% (95% CI, 79-93) in 106 samples with conjunctivitis at Aravind, India (P < .001 [Fisher exact test]). When applied to a different patient population in Thailand, the same criteria could discriminate between disease states (58 samples; sensitivity, 47%; 95% CI, 30-64 and specificity, 93%; 95% CI, 77-99; P = .001 [Fisher exact test])., Conclusions and Relevance: The results from this study suggest that the host conjunctival immune response can be meaningfully interrogated to identify biomarkers for ocular surface diseases.

In the last decade, artificial intelligence (AI) has significantly impacted ophthalmology, particularly in managing corneal diseases, a major reversible cause of blindness. This review explores AI's transformative role in the corneal subspecialty, which has adopted advanced technology for superior clinical judgment, early diagnosis, and personalized therapy. While AI's role in anterior segment diseases is less documented compared to glaucoma and retinal pathologies, this review highlights its integration into corneal diagnostics through imaging techniques like slit-lamp biomicroscopy, anterior segment optical coherence tomography (AS-OCT), and in vivo confocal biomicroscopy. AI has been pivotal in refining decision-making and prognosis for conditions such as keratoconus, infectious keratitis, and dystrophies. Multi-disease deep learning neural networks (MDDNs) have shown diagnostic ability in classifying corneal diseases using AS-OCT images, achieving notable metrics like an AUC of 0.910. AI's progress over two decades has significantly improved the accuracy of diagnosing conditions like keratoconus and microbial keratitis. For instance, AI has achieved a 90.7% accuracy rate in classifying bacterial and fungal keratitis and an AUC of 0.910 in differentiating various corneal diseases. Convolutional neural networks (CNNs) have enhanced the analysis of color-coded corneal maps, yielding up to 99.3% diagnostic accuracy for keratoconus. Deep learning algorithms have also shown robust performance in detecting fungal hyphae on in vivo confocal microscopy, with precise quantification of hyphal density. AI models combining tomography scans and visual acuity have demonstrated up to 97% accuracy in keratoconus staging according to the Amsler-Krumeich classification. However, the review acknowledges the limitations of current AI models, including their reliance on binary classification, which may not capture the complexity of real-world clinical presentations with multiple coexisting disorders. Challenges also include dependency on data quality, diverse imaging protocols, and integrating multimodal images for a generalized AI diagnosis. The need for interpretability in AI models is emphasized to foster trust and applicability in clinical settings. Looking ahead, AI has the potential to unravel the intricate mechanisms behind corneal pathologies, reduce healthcare's carbon footprint, and revolutionize diagnostic and management paradigms. Ethical and regulatory considerations will accompany AI's clinical adoption, marking an era where AI not only assists but augments ophthalmic care., (Copyright © 2024 Elsevier Masson SAS. All rights reserved.)

Purpose: To objectify the indication for re-bubbling by analyzing graft detachments (GDs) after Descemet membrane endothelial keratoplasty., Methods: In this retrospective monocentric observational study, re-bubbling cases of 450 Descemet membrane endothelial keratoplasties and the percentage of the residual gas filling (RGF) in the anterior chamber on the first postoperative day were collected. The number/location/extent of GDs and the corneal thickness above GDs were analyzed using anterior segment optical coherence tomography., Results: From a total of 450 grafts, 384 (85.3%) had at least a minimal degree GD. One hundred twenty-two of 450 grafts (27.1%) underwent at least 1 re-bubbling. The mean RGF was significantly lower in eyes with GD (67.7 ± 12.6%) than in eyes without GD (74.2 ± 11.3%). GDs occurred most frequently in the inferotemporal quadrant (46.0%). GDs were significantly more likely to require a re-bubbling when the central parts of the graft were affected (94.0% vs. 35.7%). The number of detachments per graft was directly proportional to the re-bubbling rate. The GDs which required a re-bubbling were on average 56 μm higher and 461 μm wider than the untreated ones. The cornea above the GDs that needed a re-bubbling was significantly thicker than above the untreated GDs (mean 988 ± 102 μm vs. 951 ± 99 μm)., Conclusions: The RGF seems to be a major influencing factor for graft attachment. The most susceptible location of the GD is inferotemporal. The main factors that need to be investigated to decide if a re-bubbling is required are the number of detachments per graft, their dimensions, whether the central portions of the graft are involved, and the corneal thickness above GDs., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To evaluate the corneal sensitivity of black diabetic patients and identify factors associated with changes in corneal sensitivity., Methodology: We conducted a cross-sectional comparative case-control study at the National Obesity Center of the Yaounde Central Hospital and the Djoungolo District Hospital from March 1 to July 31, 2022. Corneal sensitivity was measured using the Cochet-Bonnet esthesiometer in all diabetic patients over 18 years of age, matched for age and sex to a clinically healthy control population. Data were analyzed using SPSS version 23.0 software. A P-value of less than 5% was considered significant., Results: A total of 111 diabetic and 111 non-diabetic patients participated in the study. The mean age was 53.46±12.74 years for diabetics and 52.85±11.77 years for non-diabetics (P=0.901). The mean duration of diabetes was 6.4±5.30 years. Corneal sensitivity in diabetics was lower (44.56±9.59mm) compared to non-diabetics (53.59±6.30mm) with a statistically significant difference (P=0.000). Factors associated with decrease in corneal sensitivity in diabetics were duration of diabetes and poor glycemic control., Conclusion: Decrease in corneal sensitivity related to diabetes is a complication to be systematically screened for during the ophthalmologic follow-up of diabetic patients., (Copyright © 2024 Elsevier Masson SAS. All rights reserved.)

Purpose: To investigate the tear proteomic and neuromediator profiles, in vivo confocal microscopy (IVCM) imaging features, and clinical manifestations in neuropathic corneal pain (NCP) patients., Design: Cross-sectional study., Methods: A total of 20 NCP patients and 20 age-matched controls were recruited. All subjects were evaluated by corneal sensitivity, Schirmer test, tear break-up time, and corneal and ocular surface staining, Ocular Surface Disease Index and Ocular Pain Assessment Survey questionnaires were administered, as well as IVCM examinations for corneal nerves, microneruomas, and epithelial and dendritic cells. Tears were collected for neuromediator and proteomic analysis using enzyme-linked immunosorbent assay and data-independent acquisition mass spectrometry., Results: Burning and sensitivity to light were the 2 most common symptoms in NCP. A total of 188 significantly dysregulated proteins, such as elevated metallothionein-2, creatine kinases B-type, vesicle-associated membrane protein 2, neurofilament light polypeptide, and myelin basic protein, were identified in the NCP patients. The top 10 dysregulated biological pathways in NCP include neurotoxicity, axonal signaling, wound healing, neutrophil degradation, apoptosis, thrombin signaling mitochondrial dysfunction, and RHOGDI and P70S6K signaling pathways. Compared to controls, the NCP cohort presented with significantly decreased corneal sensitivity (P < .001), decreased corneal nerve fiber length (P = .003), corneal nerve fiber density (P = .006), and nerve fiber fractal dimension (P = .033), as well as increased corneal nerve fiber width (P = .002), increased length, total area and perimeter of microneuromas (P < .001, P < .001, P = .019), smaller corneal epithelial size (P = .017), and higher nerve growth factor level in tears (P = .006)., Conclusions: These clinical manifestations, imaging features, and molecular characterizations would contribute to the diagnostics and potential therapeutic targets for NCP., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Purpose: Our study investigates whether preoperative anterior chamber depth (ACD) measured by Scheimpflug tomography could serve as a potential predictor of graft failure in eyes undergoing Descemet stripping endothelial keratoplasty (DSEK)., Methods: A retrospective review was conducted on patients who underwent primary or repeat DSEK between January 2020 and August 2021 at Bascom Palmer Eye Institute. Charts from 378 primary and 192 repeat DSEK patients were reviewed and ultimately 47 primary and 21 repeat DSEK patients met criteria for inclusion. Data collection included demographics, preoperative ACD, best-corrected visual acuity, and length of follow-up., Results: Demographics were similar between groups, and there was no significant difference in the average best-corrected visual acuity between the single and repeat DSEK groups preoperatively. Baseline preoperative ACD was greatest in the single DSEK group (3.51 ± 0.90 mm) when compared to baseline preoperative ACD in the repeat DSEK group (3.01 ± 0.67 mm, P = 0.003). The preoperative mean ACD was smallest in the repeat DSEK group before the second DSEK (2.94 ± 0.48 mm, P = 0.001). Preoperative baseline ACD was the only variable to affect graft survival time significantly ( P = 0.012). The incidence of glaucoma diagnosis was similar in both groups (42.5% vs. 42.8%, P = 0.471). The diagnosis of glaucoma and presence of incisional glaucoma surgery did not affect the graft survival time ( P = 0.129, P = 0.559) or need for repeat DSEK., Conclusions: Smaller baseline preoperative Scheimpflug ACD measurement may be a possible predictor of the need for repeat DSEK. Our study found that Scheimpflug ACD decreases with subsequent DSEK failure., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Corneal diseases represent a growing public health burden, especially in resource-limited settings lacking access to specialized eye care. Artificial intelligence (AI) offers promising solutions for automating the diagnosis and management of corneal conditions. This narrative review examines the application of AI in corneal diseases, focusing on keratoconus, infectious keratitis, pterygium, dry eye disease, Fuchs endothelial corneal dystrophy, and corneal transplantation. AI models integrating diverse imaging modalities (e.g., corneal topography, slit-lamp, and anterior segment OCT images) and clinical data have demonstrated high diagnostic accuracy, often outperforming human experts. Emerging trends include the incorporation of biomechanical data to enhance keratoconus detection, leveraging in vivo confocal microscopy for diagnosing infectious keratitis, and employing multimodal approaches for comprehensive disease analysis. Additionally, AI has shown potential in predicting disease progression, treatment outcomes, and postoperative complications in corneal transplantation. While challenges remain such as population heterogeneity, limited external validation, and the "black box" nature of some models, ongoing advancement in explainable AI, data augmentation, and improved regulatory frameworks can serve to address these limitations., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 British Contact Lens Association. Published by Elsevier Ltd. All rights reserved.)

Purpose: Landolt ring-shaped epithelial keratopathy is a corneal disease that has only been reported in 11 Japanese patients in 2014. 1 We describe the first case of Landolt ring-shaped epithelial keratopathy in the United States in a patient of European background., Methods: This is a single case report with longitudinal care., Results: A 35-year-old White patient presented with a history of ocular burning, photophobia, and decreased vision. Corneal examination showed bilateral and asymmetric microcystic lesions in a unique Landolt ring (or the letter "C") shape, distributed randomly in the epithelium. Confocal microscopy revealed cellular ballooning and hyperreflective opacities in the basal layer of the corneal epithelium. The patient has had multiple recurrences of her symptoms year-round, each lasting 4 to 8 days. Topical treatment with cyclosporine, steroids, and lubrication resolved her symptoms but without complete resolution of signs on examination., Conclusions: Our patient's clinical signs and symptoms are similar to those described previously in 11 Japanese patients. However, unlike those patients, our patient demonstrates symptomatic response to topical treatment, no seasonal association to her condition, and to date, incomplete resolution of her disease after more than 2 years. This case highlights that Landolt ring-shaped epithelial keratopathy, a novel corneal disease of unclear origin, has relevance outside of the Japanese population., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Cystinosis is a rare autosomal recessive lysosomal storage disease associated with high mortality and morbidity rates. The most distinctive ocular manifestations of cystinosis are photophobia, tearing, and blurred vision. Herein, we assessed the ocular involvement of four patients from two families diagnosed with infantile nephropathic cystinosis using optical coherence tomography (OCT) and in vivo confocal microscopy (IVCM). Anterior segment OCT demonstrated multiple hyperreflective punctate deposits, and IVCM revealed needle-shaped bright crystal deposits in the corneal stroma in all patients. Three patients also had crystal deposits in the epithelium, where epithelial cell disruption was observed. Crystal deposits around the subepithelial nerve plexus were noted in some sections. In one patient, round and needle-shaped bright deposits along with inflammatory cells were observed in the limbal region of the conjunctiva. Infrared fundus images of two female siblings revealed hyperreflective crystal-like deposits around the optic disc, macula, and peripheral retina, and enhanced depth imaging OCT showed accumulation of crystals in all layers of the retina., Competing Interests: Conflict of Interest: No conflict of interest was declared by the authors., (©Copyright 2024 by the Turkish Ophthalmological Association / Turkish Journal of Ophthalmology published by Galenos Publishing House.)

BACKGROUND This case report illustrates the incidental detection of atypical hyporeflective bleb-like structures in an otherwise asymptomatic human cornea, highlighting the effectiveness of non-invasive biophotonic imaging techniques such as optical coherence tomography (OCT) and large-area confocal laser scanning microscopy (CLSM). CASE REPORT A 57-year-old man underwent a comprehensive ophthalmological examination, including slit-lamp biomicroscopy, corneal topography, and densitometry, as part of a clinical study. The patient presented with a clear cornea, a deep and optically empty anterior chamber, and a clear crystalline lens in both eyes. Best-corrected distance visual acuity was -0.1 logMAR. He denied ocular pain, tearing, or photophobia. There was no history of ocular trauma, infectious or genetic diseases, or ocular surgery. Further, OCT and large-area CLSM were employed for a more in-depth analysis of the corneal structure. Standard ophthalmological assessments indicated normal ocular health with no apparent corneal abnormalities. High-resolution OCT and large-area CLSM imaging revealed atypical hyporeflective bleb-like structures within the corneal epithelium and sub-basal nerve plexus but not in the stroma. CONCLUSIONS The authors hypothesize that the observed findings may indicate an early stage of epithelial basement membrane dystrophy, potentially preceding the manifestation of clinical symptoms, detectable solely through advanced biophotonic imaging methods. It is important to emphasize that these observations do not represent a definitive diagnosis. Nevertheless, the discovery of these atypical structures via advanced imaging underscores the importance of incorporating non-invasive biophotonic techniques into preoperative eye examinations in certain situations. This approach could significantly improve the early detection and management of corneal diseases, leading to improved patient outcomes.

Purpose: To describe the clinical features, management, and long-term outcome of Infectious crystalline keratopathy (ICK)., Methods: The medical records of clinically diagnosed and microbiologically proven cases of ICK were reviewed from January 2011 to December 2022. Clinical characteristics include the presence of whitish needle-like projections with branching, limited to anterior-mid stroma. Keratoplasty being the most common risk factor, graft-related microbial keratitis during the same period was also studied. The demography, clinical profile, microbiology, treatment, and outcome were analyzed, and compared with secondary graft infiltrate(GI)., Results: Medical records of 24 cases with ICK were reviewed. The mean age was 49.3 ± 20.1 years, with 15(62.5%) males. Prior keratoplasty was done in 18 (75%) cases, with a mean graft size of 10.1 ± 1.5 mm, and mean interval between the last graft and presentation was 9.7 ± 6.2 (3-90) months. In comparison to GI (n = 24), ICK patients (n = 18,75%) were less symptomatic, presented late (7.3 ± 6.5 days vs 16.3 ± 19.4, p = 0.003), using frequent topical steroids (> 3 times/day, p =  0.006), smaller infiltrate size < 4 mm (p =  0.008), central (p =  0.02), less associated with epithelial defect (p =  0.0001), hypopyon (p =  of 0.0002), corneal perforation (p =  0.0006), and surgical management (p =  0.03). On microbiology, 22 (91.6%) ICK cases were culture positive, 14 (63.6%) gram-positive, 3 (13.6%) gram-negative, 2 (9%) mixed bacteria, and 3 (13.6%) fungus, comparable with GI., Conclusion: ICK affects poor ocular surfaces usually following keratoplasty with larger graft size, the use of steroids being the most common association, and it responds to medical management as compared to GI., (© 2024. The Author(s), under exclusive licence to Springer Nature B.V.)

Background: Warburg-Cinotti syndrome is a rare syndrome caused by de novo or inherited variants in discoding domain receptor tyrosine kinase 2 (DDR2). Only six cases have been reported worldwide and our knowledge of this disease remained sparse especially from an ophthalmological perspective, since previous literature mostly focused on systemic malformations or genetics., Case Presentation: A seven-year-old boy developed a gelatinous vascularized conjunctiva-like mass secondary to trauma. The mass enlarged and gradually invaded the cornea. With each surgical intervention, the mass recurred and grew even larger rapidly. The patient ended up with the mass covering the entire cornea along with symblepharon formation. Whole exome sequencing revealed a hemizygous variant in the DDR2 gene, which is consistent with Warburg-Cinotti syndrome., Conclusions: Considering Warburg-Cinotti syndrome, we should be vigilant of patients exhibiting progressive conjunctival invasion of the cornea, even those without systemic manifestations or a positive family history., (© 2024. The Author(s).)

Objective: To describe clinical characteristics and visual outcomes of eyes developing neurotrophic keratopathy (NK) following rhegmatogenous retinal detachment (RRD) repair., Methods: All eyes with NK at Wills Eye Hospital following RRD repair from June 1, 2011, to December 1, 2020 were included. Patients with prior ocular procedures (other than cataract surgery), herpetic keratitis, and diabetes mellitus were excluded., Results: During the study period, 241 patients were diagnosed with NK, and 8179 eyes underwent RRD surgery, giving a 9-year prevalence rate of 0.1% (95% CI, 0.1%-0.2%). Mean age was 53.4 ± 16.6 years during RRD repair and 56.5 ± 13.4 years during NK diagnosis. Mean time to NK diagnosis was 3.0 ± 5.6 years (range, 6 days to 18.8 years). Mean visual acuity before NK was 1.10 ± 0.56 logMAR (20/252 Snellen), and it was 1.01 ± 0.62 logMAR (20/205 Snellen) at final visit (p = 0.75). Six eyes (54.5%) developed NK <1 year following RRD surgery. Mean final visual acuity was 1.01 ± 0.53 logMAR (20/205 Snellen) in this group versus 1.01 ± 0.78 logMAR (20/205 Snellen) in the delayed NK group (p = 1.00)., Conclusions: NK may present acutely or up to several years following surgery, with severity of corneal defects ranging from stage 1 to stage 3 NK. Surgeons should be mindful of the potential for this rare complication following RRD repair., (Copyright © 2023 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved.)

Corneal neuropathic pain (CNP) is a poorly defined disease entity characterised by an aberrant pain response to normally non-painful stimuli and categorised into having peripheral and central mechanisms, with the former responding to instillation of topical anaesthetic. CNP is a challenging condition to diagnose due to numerous aetiologies, an absence of clinical signs and ancillary tests (in vivo confocal microscopy and esthesiometry), lacking the ability to confirm the diagnosis and having limited availability. Symptomatology maybe mirrored by severe and chronic forms of dry eye disease (DED), often leading to misdiagnosis and inadequate treatment. In practice, patients with suspected CNP can be assessed with questionnaires to elicit symptoms. A thorough ocular assessment is also performed to exclude any co-existent ocular conditions. A medical and mental health history should be sought due to associations with autoimmune disease, chronic pain syndromes, anxiety and depression. Management begins with communicating to the patient the nature of their condition. Ophthalmologists can prescribe topical therapies such as autologous serum eyedrops to optimise the ocular surface and promote neural regeneration. However, a multi-disciplinary treatment approach is often required, including mental health support, particularly when there are central mechanisms. General practitioners, pain specialists, neurologists and psychologists may be needed to assist with oral and behavioural therapies. Less data is available to support the safety and efficacy of adjuvant and surgical therapies and the long-term natural history remains to be determined. Hence clinical trials and registry studies are urgently needed to fill these data gaps with the aim to improve patient care., (© 2024. The Author(s).)

Purpose: To assess incidence, risk factors, and treatment of retroprosthetic membrane (RPM) formation in eyes following Boston keratoprosthesis (Kpro) implantation and their correlation with glaucoma drainage device placement (GDD)., Methods: A retrospective review was performed on eyes that underwent Kpro type I or II implantation between 2005 and 2020 at a tertiary academic center. Multiple variables were collected including preoperative characteristics, presence of RPM, management of RPM, and outcomes including corrected visual acuity (VA). A Fischer's exact test was used to evaluate the significance of risk factors of RPM formation and an odds ratio was calculated for each possible risk factor. A Mann-Whitney U test was used to evaluate comparisons between outcomes and qualitative analyses., Results: Of the 87 eyes identified, 37 (43%) developed an RPM within an average of 1.5 years (range, 31 days-7.5 years) following Kpro implantation. Mean follow-up duration was 4.3 years. Eyes that developed RPM had significantly worse preoperative VA compared to those that did not (logMAR 2.55 vs. 2.28, p = 0.022). The mean number of prior penetrating keratoplasty procedures trended higher in eyes that developed RPM (2.46 vs. 2.18, p = 0.44) but was not significant. GDD placement after Kpro implantation was associated with an increased risk of RPM formation (RR = 1.69 p = 0.026). Of the 37 eyes that developed an RPM following Kpro, 17 (47%) were treated with Nd:YAG laser, and four of those 17 (21%) also underwent pars plana vitrectomy (PPV). Seven of 37 eyes (19%) underwent PPV without Nd:YAG. Comparisons between RPM occurrence and final VA were not significant., Conclusions: The incidence of RPM formation following Kpro implantation was 43%. Eyes that developed RPM had significantly worse preoperative VA. GDD placement after Kpro implantation increased the risk of developing RPM. Final VA and occurrence of RPM were not significantly different between the Nd:YAG and PPV treatment groups., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Various corneal diseases are strongly associated with corneal biomechanical characteristics, and early measurement of patients' corneal biomechanics can be utilized in their diagnosis and treatment. Measurement methods for corneal biomechanical characteristics are classified into ex vivo and in vivo. Some of these methods can directly measure certain corneal biomechanical parameters, while others require indirect calculation through alternative methods. However, due to diversities in measurement techniques and environmental conditions, significant differences may exist in the corneal mechanical properties measured by these two methods. Therefore, comprehensive research on current measurement methods and the exploration of novel measurement techniques may have great clinical significance. The corneal elastic modulus, a critical indicator in corneal biomechanics, reflects the cornea's ability to return to its initial shape after undergoing stress. This review aims to provide a comprehensive summary of the corneal elastic modulus, which is a critical biomechanical parameter, and discuss its direct, indirect, and potential measurement methods and clinical applications., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Purpose: The diagnosis of conjunctival squamous intraepithelial neoplasia (CSIN) can be difficult because of the heterogeneous appearance. Despite established risk factors and diagnostic support by high-resolution optical coherence tomography (hrOCT) and indocyanine green angiography (ICGA), the only reliable diagnostic method is a histological work-up. This case report is the first to describe corneal microaneurysms in CSIN as a vascular feature for conjunctival tumor angiogenesis., Methods: An 84-year-old male patient was referred with a suspected diagnosis of pterygium. Biomicroscopic examination revealed a whitish epithelial lesion of conjunctival origin with centripetal corneal growth and extension over 5 limbal hours. Intralesional vascularization showed highly altered morphology with aneurysmal changes. After imaging with hrOCT and ICGA, excision was performed in a "no-touch double-freeze and thaw" technique, followed by histological and immunohistochemical work-up., Results: hrOCT showed an epithelial, hyperreflective lesion with a maximum thickness of 272 µm and sharp central border. ICGA confirmed active perfusion and partial thrombosis of the aneurysmal terminal vascular buds dilated to 405 μm with early dye leakage within the first minute. Histological examination confirmed the clinical diagnosis of CSIN with focal high-grade dysplasia. Postoperatively, there was no recurrence during the observation period of 5 months., Conclusions: Intralesional terminal microaneurysms are a feature of tumor angiogenesis in CSIN. The relevance and frequency of this potential new risk factor for malignancy should be investigated in further studies., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

In vivo confocal microscopy (IVCM) is a unique imaging technique that permits noninvasive evaluation of the ocular surface on the cellular level. High-resolution images of all layers of the cornea are obtained in real-time with IVCM, and the acquired images are often comparable to ex vivo histochemical analysis of corneal biopsy specimens. The basic morphological features of the healthy living cornea as viewed by IVCM are reported in many domestic animal species, and the number of published descriptions of ocular surface pathologies in companion animals is progressively expanding. There is great potential for IVCM to improve the detection, characterization, and management of diverse ocular surface diseases in companion animals. This review summarizes several established and emerging clinical applications of IVCM in companion animal ocular surface disease, including infectious keratitis, corneal foreign bodies, corneal dystrophies and degenerations, ocular surface masses, corneal endotheliitis, pigmentary keratitis, and evaluation of corneal nerves.

CorneAI for iOS is an artificial intelligence (AI) application to classify the condition of the cornea and cataract into nine categories: normal, infectious keratitis, non-infection keratitis, scar, tumor, deposit, acute primary angle closure, lens opacity, and bullous keratopathy. We evaluated its performance to classify multiple conditions of the cornea and cataract of various races in images published in the Cornea journal. The positive predictive value (PPV) of the top classification with the highest predictive score was 0.75, and the PPV for the top three classifications exceeded 0.80. For individual diseases, the highest PPVs were 0.91, 0.73, 0.42, 0.72, 0.77, and 0.55 for infectious keratitis, normal, non-infection keratitis, scar, tumor, and deposit, respectively. CorneAI for iOS achieved an area under the receiver operating characteristic curve of 0.78 (95% confidence interval [CI] 0.5-1.0) for normal, 0.76 (95% CI 0.67-0.85) for infectious keratitis, 0.81 (95% CI 0.64-0.97) for non-infection keratitis, 0.55 (95% CI 0.41-0.69) for scar, 0.62 (95% CI 0.27-0.97) for tumor, and 0.71 (95% CI 0.53-0.89) for deposit. CorneAI performed well in classifying various conditions of the cornea and cataract when used to diagnose journal images, including those with variable imaging conditions, ethnicities, and rare cases., (© 2024. The Author(s).)

Objective: To investigate the clinical characteristics, associated systemic features, and management outcomes of patients with limbal dermoids diagnosed with Goldenhar syndrome., Methods: This case series included patients from the eye outpatient department, diagnosed with Goldenhar syndrome based on systemic evaluation. Demographic data, ophthalmological assessments, and systemic evaluations were recorded. Various surgical interventions were employed based on the extent of limbal dermoids, and postoperative follow-up spanned one year., Results: Seven patients (nine eyes) were included, with a mean age of 7.71±4.15 years. Limbal dermoids were bilateral in two patients and unilateral in five. Grade 1 and grade 2 limbal dermoids were observed. The mean BCVA was 0.50±0.11 (logMAR), and astigmatism was present in six patients. Systemic features of Goldenhar syndrome included vertebral anomalies, ear abnormalities, facial anomalies, and lower limb deformity. Surgical interventions varied, with simple excision, lamellar keratoplasty, and amniotic membrane transplantation utilized. Postoperatively, corneal scar formation occurred in all simple excision cases., Conclusion: This case series underscores the rarity of limbal dermoids in the context of Goldenhar syndrome and the importance of early surgical intervention in managing these cases. By sharing our experiences and outcomes, we hope to contribute to the broader understanding of this condition and its optimal treatment., Competing Interests: The authors state no conflict of interest., (© 2024 The Authors.)

Background: Corneal sensitivity can decrease by several ocular conditions , such as dry eye or refractive surgery, which favor ocular epithelial lesions and is measured using an esthesiometer. The study's primary objective was to demonstrate the efficacy and safety of the non-contact esthesiometer BRILL, which delivers air pulses to the corneal surface to assess corneal sensitivity., Methods: A single-center, prospective, controlled pilot study was carried out in adult patients with healthy eyes and or with pathology. Corneal sensitivity measurements were made in triplicate for both eyes at three consecutive visits. The esthesiometer BRILL was used in all visits , and on the last visit, the contact esthesiometer Cochet-Bonnet was also used. The results of both devices were compared by transforming them into force values., Results: 54 subjects with a mean age of 50.43 (SD 16.55, interval 18-87), 77.78% women, were included. Comparing the forces applied by both esthesiometers in the healthy eyes, in the eyes with pathology in all the groups, and in the dry eyes showed significant differences, p  = 0.03603, p  = 0.00614, and p  = 0.0001, respectively., Conclusion: The BRILL esthesiometer proved to be an effective and safe tool for non-contact assessment of corneal sensitivity with operator-independent repeatability. The measurements had a good agreement and comparable range with the Cochet-Bonet aesthesiometer measurements in healthy and dry eyes but with no interchangeable values. This portable device can help ophthalmologists and optometrists to diagnose eye pathologies that cause decreased corneal sensitivity and to assess the efficacy of therapy and disease progression., Competing Interests: Declaration of conflicting interestsJML, JL-S, and CRL have no conflicts of interest or financial ties to disclose. CGM declares that she is an employee of Brill Engines but did not receive an honorarium or another form of additional financial aid related to the development of this article.