PURPOSE: To compare early postoperative outcomes after Descemet membrane endothelial keratoplasty (DMEK) led by ophthalmology residents versus attendings at an academic institution. METHODS: This retrospective cohort stu...PURPOSE: To compare early postoperative outcomes after Descemet membrane endothelial keratoplasty (DMEK) led by ophthalmology residents versus attendings at an academic institution. METHODS: This retrospective cohort study included 99 eyes undergoing DMEK between January 2022 and December 2024 at Albany Medical Center and its affiliate cornea practice. Cases were categorized by primary surgeon as resident (postgraduate year 4) or attending. Demographic, preoperative, intraoperative, and postoperative variables were collected. The primary outcome was change in best-corrected visual acuity (logMAR). Secondary outcomes included intraocular pressure, central corneal thickness, endothelial cell density, operative time, surgical complications, and graft survival by Kaplan-Meier analysis. RESULTS: Forty-eight surgeries were resident-led and 51 attending-led. Baseline characteristics were balanced. Best-corrected visual acuity improved significantly across the cohort (F = 38.45, P < 0.001), with a mean gain of -0.25 logMAR at 8 to 16 weeks and no group difference (P = 0.192). Intraocular pressure fluctuated postoperatively and central corneal thickness decreased by -97.5 µm at 8 to 16 weeks (both P < 0.001), with neither measure differing between groups (P = 0.092 and P = 0.412). In a paired subset (n = 13), postoperative recipient endothelial cell density exceeded preoperative values by 547 cells/mm2 (P = 0.002). Operative time (34.8 vs. 35.8 minutes, P = 0.834), complication rates (25.0% vs. 27.5%, P = 0.82), and graft survival (log-rank P = 0.22) were also similar. CONCLUSIONS: Resident-led DMEK achieved comparable early postoperative outcomes to attending-led cases, supporting the inclusion of DMEK in residency curricula as a safe and effective way to expand ophthalmic surgical training.
PURPOSE: To investigate the relationship between corneal thickness and corneal astigmatism by assessing the circular pachymetry profile using Fourier analysis in normal corneas with varying degrees of regular with-the-ru...PURPOSE: To investigate the relationship between corneal thickness and corneal astigmatism by assessing the circular pachymetry profile using Fourier analysis in normal corneas with varying degrees of regular with-the-rule (WTR) astigmatism. METHODS: This cross-sectional study included 518 eyes from 259 participants with regular WTR corneal astigmatism (0-6 D). Eyes were stratified into 4 groups: <1 D (n = 176), 1 to 2 D (n = 182), 2 to 4 D (n = 108), and 4 to 6 D (n = 52). Corneal pachymetry was measured using Casia2 swept-source optical coherence tomography (SS-OCT) and analyzed via Fourier decomposition at six radii (0.5-3 mm). Harmonic amplitudes (H0-H4) represented mean thickness (H0), asymmetry (H1), toric (biaxial) variation (H2), and higher-order components (H ≥ 3). RESULTS: The Fourier model fit the pachymetry data well (mean R2 = 0.93). Amplitudes of non-zero harmonics (H1-H4) increased with greater astigmatism severity (P < 0.01), more prominently at paracentral (3 mm) than central radii (P < 0.001), and most markedly for H1 (P < 0.001). For instance, H1 amplitude rose from 7.4 ± 2.4 to 9.7 ± 4.1 at 0.5 mm and from 26.2 ± 15.8 to 51.2 ± 27.3 at 3 mm in <1 D versus 4 to 6 D groups (both P < 0.001). Post-hoc tests confirmed significant differences mainly between 4 to 6 D and lower groups. CONCLUSIONS: Corneal astigmatism showed a positive association with circular variation in corneal thickness, offering new insight into structural characteristics of astigmatic corneas.
PURPOSE: To evaluate simultaneous anterior and posterior chamber gas tamponade to improve Descemet membrane endothelial keratoplasty (DMEK) graft attachment in unicameral eyes such as in aniridia or with a history of par...PURPOSE: To evaluate simultaneous anterior and posterior chamber gas tamponade to improve Descemet membrane endothelial keratoplasty (DMEK) graft attachment in unicameral eyes such as in aniridia or with a history of pars plana vitrectomy (PPV) or glaucoma surgery. METHODS: This retrospective case series included 10 procedures in 9 complex eyes, many rendered unicameral from prior PPV or glaucoma surgery. Patients underwent DMEK (n = 7) or rebubbling (n = 3) with simultaneous anterior and posterior gas tamponade via 23-G PPV using 20% sulfur hexafluoride (SF6). Main outcomes were graft attachment, central corneal thickness (CCT), best spectacle-corrected visual acuity (BSCVA), and intraocular pressure (IOP) at 3 months. RESULTS: All 10 grafts were attached on day 1; 2 (20%) required subsequent rebubbling. At 3 months, mean CCT significantly decreased from 723.7 ± 166.2 μm to 533.9 ± 84.8 μm (P = 0.019). Mean BSCVA improved from 1.21 ± 0.85 to 0.93 ± 0.89 logMAR (P = 0.207), limited by comorbidities. Mean IOP was stable, changing from 16.9 ± 7.2 mm Hg preoperatively to 19.2 ± 12.5 mm Hg (P = 0.858). Two cases required increased glaucoma therapy; 1 graft failure was successfully managed with a repeat procedure. CONCLUSIONS: Simultaneous anterior and posterior chamber gas tamponade seems to be an effective technique for achieving DMEK graft attachment in challenging unicameral eyes after vitrectomy or glaucoma surgery. This approach may help overcome poor graft adhesion because of postoperative gas dislocation common in these conditions but necessitates combined corneal and vitreoretinal surgical expertise.
PURPOSE: Cyclosporine A (CsA) is widely used for dry eye disease (DED), yet therapeutic outcomes vary substantially across available formulations. Growing evidence suggests that formulation properties, rather than CsA co...PURPOSE: Cyclosporine A (CsA) is widely used for dry eye disease (DED), yet therapeutic outcomes vary substantially across available formulations. Growing evidence suggests that formulation properties, rather than CsA concentration alone, determine ocular surface bioavailability and clinical response. This study compared the molecular, rheological, and clinical characteristics of CsA formulations to establish a phenotype-based therapeutic selection strategy for DED management. METHODS: Human conjunctival epithelial cells under hyperosmotic stress were treated with 0.05% CsA nanoemulsion, 0.1% CsA cationic emulsion, or 0.05% CsA anionic emulsion. Expression of inflammatory cytokines (MMP-9 and TNF-α) was quantified by real-time PCR. Rheological assessments characterized viscosity and shear-thinning behavior. Clinically, 63 patients with moderate-to-severe DED were treated with either 0.05% CsA nanoemulsion or 0.1% CsA cationic emulsion for 4 months and were evaluated using OSDI, Schirmer I, tear break-up time, and ocular surface staining. RESULTS: The 0.05% CsA nanoemulsion demonstrated greater cytokine suppression and exhibited higher viscosity with greater resistance to shear, corresponding to greater improvement in Schirmer I. And 0.1% CsA cationic CsA produced a more pronounced improvement in tear break-up time, consistent with enhanced tear film spreading. Both treatments improved symptoms without serious adverse events. CONCLUSIONS: The therapeutic efficacy of topical CsA is primarily determined by formulation-tear film interactions. The 0.05% CsA nanoemulsion is more appropriate for aqueous-deficient DED, where prolonged ocular residence supports tear volume recovery, whereas 0.1% CsA cationic emulsion is better suited for tear-film instability or evaporative DED, where improved spreading enhances tear film stability. These results support phenotype-based selection of CsA formulations to optimize treatment precision.
PURPOSE: The aim of this study was to assess the presence of interface fluid at the end of Descemet membrane endothelial keratoplasty (DMEK) and to analyze the impact of this interface fluid on the postoperative graft de...PURPOSE: The aim of this study was to assess the presence of interface fluid at the end of Descemet membrane endothelial keratoplasty (DMEK) and to analyze the impact of this interface fluid on the postoperative graft detachment rate. METHODS: At the end of DMEK, after clinically satisfactory graft adhesion, corneas were imaged intraoperatively using optical coherence tomography. The number of interface fluid zones was counted using a custom-written computer script. These zones were classified according to their size (small or large) and their location (graft center or periphery). The rebubbling rate for each patient was recorded. RESULTS: A total of 69 eyes of 69 patients undergoing DMEK surgery were included in this analysis. There was a considerable difference in the number of graft detachments detected between the patients, with a mean number of 2.19 ± 1.94 small central, 2.97 ± 3.11 small peripheral, 0.51 ± 0.90 large central, and 0.81 ± 1.35 large peripheral interface fluid collection sites per eye. A total of 55 patients required no rebubbling, while 10 patients required one, three patients required two, and one patient required three rebubblings. A statistically significant correlation was observed between the number of large peripheral detachments and the rebubbling rate (r = 0.368, P = 0.002). CONCLUSIONS: Patients with incomplete graft attachment at the end of DMEK surgery demonstrated increased rebubbling rates. Corneal surgeons might detect these detachments using intraoperative optical coherence tomography and modify their surgical technique to reduce them. Furthermore, curvature matching between the host and the recipient might decrease the occurrence of interface fluid accumulation.
PURPOSE: Keratoprosthesis offers certain pediatric patients with congenital corneal opacity an alternative for improving vision. Pars plana vitrectomy (PPV) combined with Boston keratoprosthesis type 1 (KPro) has demonst...PURPOSE: Keratoprosthesis offers certain pediatric patients with congenital corneal opacity an alternative for improving vision. Pars plana vitrectomy (PPV) combined with Boston keratoprosthesis type 1 (KPro) has demonstrated success in reducing postoperative complications such as retinal detachment (RD) in adults. However, its role and outcomes have yet to be investigated in pediatric patients. This study investigates the outcomes of PPV in KPro pediatric patients, with a focus on prosthesis retention, visual acuity (VA), and postoperative complications. METHODS: We performed a retrospective review of all pediatric patients who underwent PPV with KPro at a tertiary care center in Rochester, NY. Surgeries were performed between 2011 and 2016. Postoperative complications measured included RD, retroprosthetic membrane, and corneal melt. Additional outcomes included prosthesis retention, VA, and time to complications. RESULTS: A combined KPro and PPV procedure was performed in 18 eyes from 15 pediatric patients, with follow-up ranging from 6 months to 10 years (median: 3.92 years). The overall KPro retention rate was 67%. Preoperative VA ranged from light perception to fix and follow, and among eyes with preoperative and postoperative VA data (11), six eyes (54.5%) improved, three (27.3%) remained the same, and two (18.2%) declined. RD occurred in eight of 18 eyes, retroprosthetic membrane developed in 11 of 18 eyes, and corneal melt occurred in 15 of 18 eyes. CONCLUSIONS: Our findings suggest that PPV may improve pediatric KPro outcomes, providing valuable insights into restoring functional vision in children with congenital corneal opacity.
PURPOSE: We aimed to evaluate safety, indications, and patient satisfaction for keratopigmentation (KTP) with microneedling in patients with corneal leukoma. MATERIALS AND METHODS: This retrospective study included patie...PURPOSE: We aimed to evaluate safety, indications, and patient satisfaction for keratopigmentation (KTP) with microneedling in patients with corneal leukoma. MATERIALS AND METHODS: This retrospective study included patients who underwent KTP using a microneedling device (Dermapen) between January 2020 and May 2025. A total of 11 eyes from 11 patients with corneal leukoma were included. KTP was performed under sterile conditions and topical anesthesia, using the Dr. Pen Ultima N2-W Dermapen device. Sterile skin tattoo pigments, selected to match the color of the fellow eye, and approved by the European Union REACH (Registration, Evaluation, Authorization, and Restriction of Chemicals) were used, without dilution. RESULTS: The underlying causes of corneal leukoma included trauma in four cases, keratoplasty rejection in three cases, bullous keratopathy in one case, Peters anomaly in one case, congenital glaucoma in one case, and phthisis secondary to glaucoma in one case. The mean procedure time in all patients was calculated as 35.6 ± 12.3 minutes. Corneal epithelium healed and conjunctival hyperemia resolved within 1 week in all patients. The mean follow-up period was 17.06 ± 7.3 months (8-39 months). All patients demonstrated aesthetic improvement in ocular appearance postoperatively. No significant pigment fading or migration (>10% surface area) occurred, and cosmetic outcomes remained stable without need for repeat pigmentation. No additional surgical intervention or repigmentation was required. CONCLUSIONS: Dermapen is a device that offers a practical and homogeneous method for corneal KTP. The ability to adjust the needle depth allows for a personalized treatment approach.
PURPOSE: To study the use of autologous injectable platelet-rich fibrin (iPRF) and tranexamic acid (TA) for conjunctival autograft (CAG) adherence during pterygium surgery. METHODS: This case series report included 212 p...PURPOSE: To study the use of autologous injectable platelet-rich fibrin (iPRF) and tranexamic acid (TA) for conjunctival autograft (CAG) adherence during pterygium surgery. METHODS: This case series report included 212 primary nasal pterygiums from 205 patients who underwent pterygium excision with conjunctival autograft fixation using iPRF and TA operated by a single surgeon at 1 center. Surgical time, postoperative graft stability, and recurrence were assessed, and outcomes were compared with literature reports of autologous blood (ATB) and commercial fibrin glue (FG). RESULTS: The average age was 57.8 years (range 33-75 years). The average surgical duration was 15.3 minutes (12.2-21.4 minutes). Graft dislodgement was noted in 1 eye (0.47%) on day 1, requiring reprocedure. Recurrence was observed in 2 patients (0.94%), mild graft edema in 68 eyes (32.07%), late spontaneous hemorrhage under CAG in 34 eyes (16%), and graft retraction in 2 eyes (0.94%). No postoperative infections, local inflammation, thrombotic complications, or systemic adverse effects were observed. The recurrence rates were lower than those reported for ATB. Unlike FG, iPRF contains platelets and leukocytes, which contribute to angiogenesis and wound healing. The addition of TA stabilizes the fibrin network by inhibiting fibrinolysis, thereby enhancing the adhesion. The cost incurred when using iPRF was 50x lower than that of Baxter Tisseel. CONCLUSIONS: iPRF combined with TA is a safe, autologous, and cost-effective alternative to ATB, sutures, and FG for CAG fixation in pterygium surgery. Larger randomized controlled trials are required to validate the findings of this novel method.
PURPOSE: The aim of this study was to report the outcomes of "peeling-off spiral" deep anterior lamellar keratoplasty (DALK), a manual DALK technique that allows for a deep, fast, and reliable stromal removal, taking adv...PURPOSE: The aim of this study was to report the outcomes of "peeling-off spiral" deep anterior lamellar keratoplasty (DALK), a manual DALK technique that allows for a deep, fast, and reliable stromal removal, taking advantage of the lowest adhesion among the posterior stromal lamellae. METHODS: This was a retrospective case series of patients who underwent "peeling-off spiral" DALK between January 2014 and September 2024, with at least 1 year of follow-up. Indications for DALK, intraoperative and postoperative complications, residual recipient bed thickness, and postoperative best corrected visual acuity (BCVA) at 1 year of follow-up were evaluated. RESULTS: A total of 149 DALK eyes (122 patients) underwent "peeling-off spiral" DALK for corneal ectasia (87 eyes), stromal scar (31 eyes), and active infection (31 eyes). In cases of previous hydrops or full-thickness penetrating corneal wound (9 eyes), a modified "assisted peeling-off spiral" DALK procedure was performed, where the peeling of the stroma was aided by a crescent blade to reduce the pulling force and avoid enlargement of the preexisting DM break. Six intraoperative ruptures were recorded (4%); however, 3 were preexisting DM breaks from previous hydrops, 2 were reopenings of previous full-thickness corneal penetrating wounds, and only 1 (0.7% of cases without preexisting breaks) was a new intraoperative DM rupture. The mean residual recipient bed thickness was 40.1 μm at 1 day postoperatively (range 21-131 μm) and 28.4 μm (range 17-85 μm) at 3 months postoperatively. The mean postoperative BSCVA at 1 year of follow-up was 0.73 ± 0.19 (range 0.4-1.0). CONCLUSIONS: "Peeling-off spiral" DALK is a valuable and reliable manual technique that achieves a deep stromal plane, with favorable visual outcomes and a low rate of complications.
PURPOSE: To evaluate clinical outcomes of conjunctival flap surgery in the management of refractory infectious keratitis at a tertiary care center. METHODS: This retrospective, single-center case series included patients...PURPOSE: To evaluate clinical outcomes of conjunctival flap surgery in the management of refractory infectious keratitis at a tertiary care center. METHODS: This retrospective, single-center case series included patients who underwent complete or partial conjunctival flaps for infectious keratitis at the Bascom Palmer Eye Institute between January 2015 and March 2023. Cases were identified via Current Procedural Terminology codes and confirmed by chart review. Surgical success was defined as infection resolution without further surgery or ongoing antimicrobial therapy. Independent samples t tests and χ 2 tests compared continuous and categorical variables, respectively. Kaplan-Meier survival analysis evaluated time to resolution, with group differences assessed using log-rank and generalized Wilcoxon tests. RESULTS: Nine patients (43%) received complete flaps, and 12 (57%) received partial flaps. Surgical success was achieved in 55.6% of complete flaps and 66.7% of partial flaps. Larger ulcer area was associated with flap failure ( P = 0.021). Best-corrected visual acuity at last follow-up was better ( P = 0.043) among partial flap cases (1.7 ± 1.0 logMAR) compared with those of complete flaps (2.7 ± 0.7 logMAR). Kaplan-Meier survival analysis showed that time to resolution differed by flap type according to the Wilcoxon test ( P = 0.029) and a trend toward significance by the log-rank test ( P = 0.053), suggesting earlier resolution among partial flap cases. CONCLUSIONS: Conjunctival flaps achieved infection resolution in most cases of refractory infectious keratitis, with partial flaps showing slightly higher overall success and earlier resolution. These findings support conjunctival flaps as a salvage option, particularly in resource-limited or refractory settings, although further prospective evaluation is warranted.
PURPOSE: The aim of this study was to analyze the influence of donor characteristics and tissue preservation conditions on the scrolling behavior of grafts in Descemet membrane endothelial keratoplasty (DMEK). METHODS: T...PURPOSE: The aim of this study was to analyze the influence of donor characteristics and tissue preservation conditions on the scrolling behavior of grafts in Descemet membrane endothelial keratoplasty (DMEK). METHODS: This retrospective, single-center study included 3150 consecutive DMEK grafts after uneventful preparation for DMEK surgery. The grafts were prepared from either organ-cultured corneoscleral buttons (n = 1414) or corneoscleral buttons stored in Optisol-GS (n = 1736). The main donor characteristics were age, endothelial cell density, death-to-preservation time, preservation method, and storage duration. The thickness of Descemet membrane (DM) was analyzed in a subgroup of 74 grafts using transmission electron microscopy. Scrolling behavior was quantified as roll width using calipers (mm). RESULTS: Older donor grafts exhibited less pronounced scrolling, with a significant correlation between donor age and roll width (r = 0.561, P < 0.001, R2 = 0.308). Organ-cultured grafts exhibited larger roll widths (1.764 ± 0.65 mm) than Optisol-GS-stored grafts (1.516 ± 0.51 mm; P < 0.001). A significant correlation was found between DM thickness and roll width (Spearman ρ = 0.562, P < 0.001, R2 = 0.312), while DM thickness was also significantly correlated with donor age (r = 0.545, P < 0.001, R2 = 0.304). CONCLUSIONS: In this large cohort of DMEK grafts, donor age was confirmed as the most decisive factor influencing the scrolling behavior of DMEK grafts, with younger tissues demonstrating tighter scroll formation while the correlation gradually weakened in older donor groups. The DM thickness was confirmed as an independent contributor, as thicker membranes were associated with less tightly scrolled grafts.
PURPOSE: To investigate dysregulated ion channels and epithelial-to-mesenchymal transition (EMT) genes in Fuchs endothelial corneal dystrophy (FECD) and to identify potential drugs interacting with dysregulated ion chann...PURPOSE: To investigate dysregulated ion channels and epithelial-to-mesenchymal transition (EMT) genes in Fuchs endothelial corneal dystrophy (FECD) and to identify potential drugs interacting with dysregulated ion channels. METHODS: Five RNA-sequencing datasets from patients with FECD were analyzed with DESeq2 to identify differentially expressed genes. Dysregulated ion channels and EMT-related genes underwent enrichment analysis and EMT scoring via the KS method. Coexpression patterns were identified using weighted gene coexpression network analysis. A pathway map highlighted altered cellular processes in FECD, and potential drugs were identified using the Drug-Gene Interaction Database. Molecular docking assessed binding of drugs with TRPV4 and TRPM8 . Selected gene expression changes were validated by quantitative real-time polymerase chain reaction. RESULTS: Analysis identified 12,550 differentially expressed genes, including 229 ion channels (157 up-regulated, 72 down-regulated) and 502 EMT-related genes (304 up-regulated, 198 down-regulated). Functional enrichment revealed disrupted biological processes including interleukin-1 production and extracellular matrix organization organization. Coexpression analysis uncovered 2 modules linked to apoptosis and senescence. Up-regulated transient receptor potential cation (TRP) cation channels correlated with elevated senescence; altered NFKBIA , NFKB1 , and TNFSF10 expression with endothelial apoptosis. We identified 1052 drugs targeting 133 dysregulated ion channels and performed docking analysis for TRP channels. Experimental validation confirmed altered expression of TRPV1 , CDKN2A , and KRT7 . CONCLUSIONS: Dysregulated TRP cation channels contribute to cellular senescence and peripheral sensitization in FECD, whereas altered apoptotic regulators drive corneal endothelial cell death. Most likely, these pathways represent potential targets for treatment of patients with FECD.
PURPOSE: To characterize, for the first time, corneal sensory nerve functionality in congenital aniridia by assessing mechanical and cold corneal sensitivity, reflex tearing, and basal blinking and tearing. METHODS: A co...PURPOSE: To characterize, for the first time, corneal sensory nerve functionality in congenital aniridia by assessing mechanical and cold corneal sensitivity, reflex tearing, and basal blinking and tearing. METHODS: A cohort of fourteen pediatric and adult patients with PAX6-related aniridia was enrolled in the study. Mechanical sensitivity (noncontact gas esthesiometer) and cold sensitivity (4°C drops) were quantified using a 0 to 10 verbal numerical scale (VNS). Spontaneous blinking, basal, and CO2-induced reflex tearing were also measured. Data were stratified by age, aniridia-associated keratopathy (AAK), and PAX6 mutation type-reduced expression or loss-of-function (LOF) genetic variants-and compared with healthy controls (n = 9). RESULTS: Mechanical sensitivity to high-intensity stimuli was reduced in patients with aniridia, particularly in adults (2.2 ± 0.3 VNS, P = 0.02), those with severe AAK (2.4 ± 0.4 VNS, P = 0.09), and patients with LOF mutations (2.4 ± 0.2 VNS, P = 0.05) compared with controls (3.9 ± 0.5 VNS). Cold sensitivity was also reduced in adult patients (5.5 ± 0.5 vs. 3.8 ± 0.6 VNS, P = 0.05) and severe AAK (3.2 ± 0.8 VNS, P = 0.01). Reflex tearing values exhibited variability but trended lower in patients than controls, and tearing reserve (reflex minus basal tearing) was significantly reduced (12.7 ± 3.8 vs. 1.9 ± 1.9 mm, P = 0.02). Basal blinking and tearing were not significantly different. CONCLUSIONS: These findings suggest impaired mechano-nociceptors, polymodal nociceptors, and cold thermoreceptors function in congenital aniridia, with severity increasing with age and AAK grade. LOF mutation results show a trend with greater deficits than reduced expression variants, highlighting a critical role of PAX6 in corneal sensory integrity.
PURPOSE: To develop and validate an artificial intelligence (AI)-enabled eye rubbing detection tool using sensor data collected from wrist-based wearable devices. METHODS: An automated system was designed to detect eye r...PURPOSE: To develop and validate an artificial intelligence (AI)-enabled eye rubbing detection tool using sensor data collected from wrist-based wearable devices. METHODS: An automated system was designed to detect eye rubbing using wrist-based wearable devices. The system involves 3 components: sensor data acquisition, data preprocessing, and deep learning-based classification model. Six different deep learning architectures were developed, including 1D and 2D CNN-LSTM models and an ensemble, to identify the most effective approach. Two datasets were established in the time and frequency domains: a timeseries dataset contains 8640 recordings and a scalogram dataset 15 comprising 112,320 images from 20 subjects. RESULTS: The proposed system demonstrated strong performance, achieving an F1-score of 95.27 ± 0.87% and AUC of 98.26 ± 0.92% across 5 cross-validation folds when using the 1D CNN-LSTM model to distinguish eye rubbing and noneye rubbing activities. When evaluated on the testing set, the system maintained high performance, with an F1-score of 92.54% and AUC of 96.70%. Model inference required 15.32 milliseconds per segment, supporting real-time operation and practical deployments. CONCLUSIONS: The proposed system provides high reliability in detecting eye rubbing behaviors, indicating its potential as a tool to support ophthalmologists and researchers in the rigorous study of the contributions of eye rubbing to the development and progression of keratoconus and other corneal ectasias.