Samer Hamada

Childhood blepharokeratoconjunctivitis: characterising a severe phenotype in white adolescents

Background The syndrome of childhood blepharokeratoconjunctivitis (BKC) is frequently underestimated. While prevalent and aggressive among Indo-Pakistani/Middle-Eastern populations, we observe a recalcitrant destructive phenotype in white children/adolescents that persists into early adulthood and may require systemic immunosuppression. Methods A cohort of 10 white patients (20 eyes), median age 15.2 (range 6–27) years were identified among 62 patients with BKC attending a tertiary referral centre. Clinical features were graded and lid/conjunctiva swabs were performed, before instituting a hierarchical therapeutic protocol comprising lid hygiene, topical/systemic antibiotics, intensive topical glucocorticoids and systemic immunosuppression. Results The median duration of symptoms prior to presentation was 4.3 (range 1.2–16.3) years, with 14 eyes (nine patients) demonstrating 360° peripheral corneal vascularisation associated with encroachment/involvement of the visual axis in 10 eyes (six patients). Corneal perforation(s) occurred in three eyes (two patients). Intensive topical glucocorticoids enabled disease control in 10 eyes (seven patients). In six eyes (three patients), persistent active disease necessitated systemic immunosuppression (azathioprine (2), mycophenolate mofetil (1), prednisolone (1)) achieving disease remission within three months with no adverse events reported. Conclusions Suboptimal treatment of BKC in white children may permit a progressively destructive sight-threatening phenotype, which may last into adulthood and require immunosuppression. Appropriate aggressive steroid-based and steroid-sparing strategies are vital for disease remission.

Infectious crystalline keratopathy treated with intrastromal antibiotics.

An 84-year-old white female with nonprogressive conjunctival scarring developed infectious crystalline keratopathy (ICK) recalcitrant to topical therapy. After determination of the causative organisms antibiotic sensitivities, superficial keratectomy was performed with intrastromal corneal infiltration of cefuroxime into the affected cornea. Postoperatively, the ICK resolved completely, leading to an improvement in visual acuity and a reduction in ocular irritation. This case highlights the importance of a surgical approach in ICK and also demonstrates the possible benefit of a novel use of intracorneal antibiotics as an adjunct.

Deep anterior lamellar keratoplasty over penetrating keratoplasty for host rim thinning and ectasia.

Purposes: To describe the technique and evaluate the outcomes of patients who had deep anterior lamellar keratoplasty (DALK) for ectasia within or outside the graft-host interface in a previous penetrating keratoplasty (PK). Design: Retrospective review of interventional case series. Patients: Seven eyes that underwent DALK for corneal ectasia after previous PK. Intervention: DALK encompassing the area of ectasia and the previous PK. Main outcome measures: Uncorrected visual acuity, best spectacle-corrected visual acuity, keratometry and topography, and complications. Results: Seven eyes had DALK, 4 developed Descemet membrane tears, and 2 eyes had deep graft-host dehiscence from the previous PK intraoperatively. At 12 months, mean uncorrected visual acuity (logarithm of the minimum angle of resolution) improved from 1.157 to 0.74. Mean best spectacle-corrected visual acuity improved from 0.82 to 0.37 at 12 months. Conclusions: DALK can be successfully performed over a previous PK. Intraoperative Descemet tears or dehiscence of Descemet at the previous graft-host interface can complicate surgery, but if successfully managed can produce a significant improvement in visual acuity.

Refractive Nightmares Revisited: Calcification of a Multifocal Intraocular Lens

Background/Aim: Cataract is the leading cause of reversible blindness and visual impairment worldwide. Although cataract surgery using phacoemulsification and intraocular lens (IOL) implantation is one of the commonest surgical procedures, IOL opacification remains a potential complication that can affect the visual outcome of the operation. Case Report: A 50-year-old female patient presented to our clinic complaining of glare and blurry vision in her right eye over the previous 6 weeks. She had undergone bilateral refractive lens exchange elsewhere 9 months earlier. Her unaided distance visual acuity was 8/10 in the right eye and 10/10 in the left. On slit-lamp examination, we observed the presence of in-the-bag, multifocal, hydrophobic acrylic IOLs bilaterally. Specifically, calcified deposits within the substance of the IOL were observed. Conclusion: To our knowledge, this is the first case of spontaneous calcification of a hydrophobic multifocal IOL and all cataract/refractive surgeons should be aware of this rare complication.

Therapierefraktäre periphere ulzerative Keratitis bei junger Patientin

Eine 48-jährige Patientin wurde in unser Hornhautzentrum am Queen Victoria Hospital mit einem seit 4 Wochen bestehenden peripheren Hornhautbefund im Sinne einer Ulzeration, begleitet von einer Bindehautinjektion am linken Auge, zugewiesen. Die initiale Behandlung durch den niedergelassenen Augenarzt mit Neomycin/Polymyxin-B-Sulfat (Maxitrol®)-Augentropfen 4-mal täglich und anschließend Dexamethason 0,1%Augentropfen 4-mal täglich sowie Doxycyclin 100mg Tabletten 1-mal täglich per os führte zu keiner Besserung des Befundes. Die übrige ophthalmologische, systemische wie soziale Anamnese der Patientinwar bis dahin völlig unauffällig. Die ophthalmologische Untersuchung ergab am betroffenen linken Auge einen bestkorrigierten Dezimalvisus von 0,63, der Intraokulardruck lag bei 16mmHg. An der Hornhaut zeigte sich nasal inferior ein 1× 2mm großer Hornhautdefekt, die umgebende Konjunktiva war mäßig injiziert, in der Vorderkammer fand sich ein leichter Reiz mit (+) Zellen, die eigene Linse lag altersentsprechend am Ort (. Abb. 1). Der hintere Augenabschnitt am betroffenen Auge sowie der vordere und hintere Augenabschnitt am Partnerauge zeigten sich dabei völlig bland. Bei dem dringenden Verdacht auf eine therapierefraktäre periphere ulzerative Keratitis (PUK) veranlassten wir sogleich eine ausführliche serologische Abklärung einschließlich großem Blutbild, Leberund Nierenwerten, Urinstatus, ACE, bestimmten Antikörpern gegen Lues, Borrelien, Tuberkulose, ANA, ANCA, Anti-dsDNA, HIV, Hepatitis B und C sowie Komplementfaktoren und Blutglukose. Zusätzlich wurden Hornhautkratzabstriche entnommen sowie eine Röntgenuntersuchung des Thorax initiiert. Unsere Abklärung ergab eine positive Serologie auf Hepatitis C sowie 4-fach erhöhte Transaminasen. Alle weiteren insbesondere rheumatologischen Markerwaren negativ. DieHornhautkratzabstriche sowie die Röntgenuntersuchung des Thorax zeigten keinen auffälligen Befund. Anamnestisch ließ sich die Genese der Hepatitis-C-Infektion nicht mehr eruieren; die Patientin gab weder an, jemals eine Bluttransfusion erhalten zu haben, noch zu einer der anderen Risikogruppen dazuzugehören.

Multiple pit defects of unknown etiology in a foldable hydrophobic intraocular lens

A 56‐year‐old female patient presented to our clinic for a routine follow‐up appointment after penetrating keratoplasty and cataract surgery (triple procedure) for a deep corneal scar due to previous herpetic keratitis. The procedure was performed 9 months before the recent presentation. Her unaided visual acuity was 2/10 OD and 10/10 OS. On slit‐lamp examination, the corneal graft OD appeared clear, and the anterior segment OS was healthy with bilateral pseudophakia. However, we unexpectedly observed that there were multiple pits on the anterior surface of the intraocular lens (IOL) OD [Figure 1], which was a hydrophilic, one‐piece, in‐the‐bag IOL. The patient did not undergo any YAG capsulotomy or vitrectomy with silicone oil tamponade. She had not experienced any intraocular infection or corneal graft rejection episodes since undergoing ocular surgery.

Effect of Conus Eccentricity on Visual Outcomes After Intracorneal Ring Segments Implantation in Keratoconus

PURPOSE To investigate the potential impact of cone eccentricity on visual outcomes after Keraring (Mediphacos, Belo Horizonte, Brazil) implantation for keratoconus. METHODS Nineteen eyes from 19 patients with keratoconus who underwent femtosecond laser-assisted Keraring implantation for keratoconus were included in this retrospective study. Uncorrected visual acuity (UDVA), corrected visual acuity (CDVA), keratometric readings, central corneal thickness, maximum keratometric distance from corneal apex (DKmax), corneal thinnest point from corneal apex (DTh), and coma were evaluated preoperatively and 6 months after the Keraring implantation. DKmax and DTh were used as metrics reflecting the eccentricity of the cone. RESULTS UDVA, CDVA, keratometric readings, and coma improved at 6 months postoperatively. However, there was no correlation between DKmax or DTh and visual outcomes at 6 months postoperatively. CONCLUSIONS The data did not show any impact of the cone eccentricity on visual outcomes after Keraring implantation for keratoconus at 6 months postoperatively. [J Refract Surg. 2018;34(3):196-200.].

Ocular Surface Disease: Advances in Diagnostics and Therapeutics

Ocular surface disease is an umbrella term that includes a variety of complex pathologies such as Stevens–Johnson syndrome, mucous membrane pemphigoid, limbal stem cell insufficiency, dry eye disease, and ocular graft-versus-host disease. Regardless of the underlying disease process, ocular surface failure may result in inflammatory and infectious complications and potentially devastating visual loss. Early diagnosis and appropriate treatment of ocular surface disease require a high level of expertise as these conditions can be extremely challenging even for experienced clinicians. Although key issues in the management of patients with complex ocular surface disease still remain controversial, recent advances in diagnostics and therapeutics have enhanced our armamentarium and allow for improved clinical outcomes. In our special issue on ocular surface disease, WróbelDudzińska et al. report on the clinical efficacy of platelet-rich plasma in the management of neurotrophic corneal ulcer, showing promising clinical results. Hazarbassanov et al. assess the effect of osmoprotection in themanagement of dry eye disease after refractive surgery in a randomized controlled double-blind clinical trial, while Moussa et al. investigate the effect of different prostaglandin analogues on the ocular surface of patients with primary open-angle glaucoma. Krysik et al. report on indications, outcomes, and complications of penetrating keratoplasty for ocular surface disease-related pathologies in a tertiary referral center, whereas Sun et al. analyze the therapeutic effects of corneal debridement combined with intrastromal voriconazole in a patient series with recalcitrant fungal keratitis. Ikegawa et al. investigate, with the aid of in vivo confocal microscopy, the morphology of two types of vortex keratopathy: amiodarone-induced keratopathy and the Fabry disease-associated keratopathy. Finally, Moschos et al. explore the psychological aspects and the incidence of depression in patients with symptomatic keratoconus.

An in-vivo comparison of two tear osmometers

Dry eye disease (DED) is defined by the Dry Eye Workshop (DEWS) as “a multifactorial disease of the ocular surface characterized by a loss of homeostasis of the tear film, and accompanied by ocular symptoms, in which tear film instability and hyperosmolarity, ocular surface inflammation and damage, and neurosensory abnormalities play etiological roles.” Given the central importance of hyperosmolarity in the pathophysiology DED, there is significant interest in clinical measurement of tear osmolarity as part of the diagnosis and ongoing management of DED. There are several methods available to measure tear osmolarity. Historically freezing point depression osmometers and vapour pressure osmometers have been used to measure tear osmolarity. These osmometers involve quite a complex process of tear osmolarity determination better suited to a research, rather than a clinical, setting. Both instruments require collection of tears using micropipettes and a significant degree of expertise is required to obtain accurate measurements. More recently, other osmometers have been developed which are more suitable to a clinical environment. Two of these are the TearLab (TearLab Corporation, San Diego, California) and the i-Pen (i-Med Pharma, Dollard-des-Ormeaux, Quebec, Canada). Both the TearLab and the i-Pen, measure electrical impedence to determine osmolarity. The TearLab uses a disposable test card attached to a collection pen is used to obtain a sample of tears from the inferotemporal tear meniscus. Less than 20 nL of fluid is required for osmolarity testing. The i-Pepm (I-Med Pharma) employs disposable strips which measure tear osmolarity when touched against the tarsal conjunctiva of the lower lid. The purpose of the current study was to assess the agreement between two tear osmolarity measuring devices, the iPEN and the TearLab. Ethics approval was obtained from the hospital ethics committee. Consent was obtained from all participants. All procedures were followed in accordance with the Helsinki Declaration of 1964, as revised in 2013. Fifty-seven eyes of 31 consecutive patients attending the Corneoplastic Unit at Queen Victoria Hospital, East Grinstead, UK had tear osmolarity tested with both devices at the same time during the same visit. Patients had been referred for a variety of corneal or oculoplastic disease, not specifically dry eye disease. Patients without a prior diagnosis of DED were chosen as these devices have been developed as diagnostic tools for DED. Calibration was performed for the TearLab daily and was not required for the i-PEN as per the manufacturer instructions.

Update on corneal neurotisation

Corneal neurotisation describes surgical restoration of nerve growth into the cornea to restore corneal sensation and trophic function. It represents an exciting and effective emerging treatment for neurotrophic keratopathy. Techniques described to date involve either direct nerve transfer or an interpositional nerve graft coapted to a healthy donor nerve. We review the experience to date with particular emphasis on a detailed review of techniques, outcomes and current thoughts.