PURPOSE: To describe a novel technique for managing anterior chamber (AC) instability during endothelial keratoplasty in eyes with compromised anterior segment architecture through posterior segment pressurization via in...PURPOSE: To describe a novel technique for managing anterior chamber (AC) instability during endothelial keratoplasty in eyes with compromised anterior segment architecture through posterior segment pressurization via intravitreal balanced salt solution (BSS) injection. METHODS: In eyes with distorted iris anatomy, large peripheral iridectomies, prior vitrectomy, or iris-lens diaphragm instability undergoing Descemet stripping automated endothelial keratoplasty (DSAEK) or Descemet membrane endothelial keratoplasty, intraocular air or gas may migrate posteriorly, destabilizing the AC and compromising graft apposition. We describe a technique in which approximately 0.2 mL of BSS is injected through the pars plana into the vitreous cavity using a 30-gauge needle, providing transient posterior segment pressurization to stabilize the globe. After injection, the needle is maintained in position with gentle plunger control for approximately 2 minutes to allow stabilization of posterior segment pressure and sustained globe firmness. RESULTS: The technique was successfully applied in 3 complex cases: 1) an 81-year-old man with atonic pupil, postvitrectomy, and glaucoma tube shunt undergoing DSAEK; 2) an 82-year-old female postvitrectomy patient undergoing DSAEK; and 3) 77-year-old man with large peripheral iridectomy undergoing Descemet membrane endothelial keratoplasty. All cases achieved stable AC configuration and secure graft attachment without excessive air/gas fill or posterior gas migration. CONCLUSIONS: Posterior intravitreal BSS injection provides an effective method to stabilize the iris-lens diaphragm and maintain AC architecture during endothelial keratoplasty when conventional air/gas injection alone is insufficient.
PURPOSE: To report the graft detachment and rebubbling rate of pre-Descemet endothelial keratoplasty (PDEK) in patients with Fuch dystrophy and pseudophakic bullous keratopathy. METHODS: In this prospective interventiona...PURPOSE: To report the graft detachment and rebubbling rate of pre-Descemet endothelial keratoplasty (PDEK) in patients with Fuch dystrophy and pseudophakic bullous keratopathy. METHODS: In this prospective interventional study of 131 eyes (131 patients), the main-outcome measures were visual acuity, graft detachment and rebubbling rate, pachymetry, and endothelial cell count (ECD) loss. RESULTS: The mean age of graft recipients was 64.5 ± 12.3 years(range 21-87 years); the mean donor age was 25.1 ± 8.7 years(range 10-70 years); and mean graft size was 7.5 ± 0.4 mm. Four eyes (3%) experienced partial graft detachment. Inferotemporal detachment was detected in 2 eyes, inferior in 1 eye, and central detachment in 1 eye. Two cases with graft detachment had no air bubble in the anterior chamber and 2 cases had less than 20% air in anterior chamber on the first postoperative day (POD). The graft detachment was detected on first POD in 2 cases, on second POD in 1 case and on third POD in 1 case. The mean ECD loss was 22.3%, whereas the ECD loss for eyes that underwent rebubbling was 24.8%. There was significant improvement in visual acuity (P < 0.001). Postoperative best-corrected visual acuity was not dependent on donor age, donor specular count, or PDEK graft size. There was no significant correlation between ECD loss and postoperative best-corrected visual acuity (P = 0.524). The mean preoperative central corneal thickness was 758 ± 152.1 μm, whereas the mean postoperative central corneal thickness was 541.3 ± 90.8 μm (P = 0.000). No incidence of graft failure or rejection was observed during 18 months of follow-up. CONCLUSIONS: PDEK offers satisfactory visual outcomes and has a favorable complication profile with lower rate of graft detachment and rebubbling rate of 3%.
PURPOSE: To report a case of benign conjunctival and corneal epithelial hyperpigmentation associated with long-term osimertinib use. METHODS: observational case report. RESULTS: An incidental finding of bilateral benign...PURPOSE: To report a case of benign conjunctival and corneal epithelial hyperpigmentation associated with long-term osimertinib use. METHODS: observational case report. RESULTS: An incidental finding of bilateral benign hyperpigmentation of the conjunctiva and corneal epithelium was noted in an Asian woman in her sixth decade. Pigmentation involved the caruncle and extended to the lid margins in both eyes. Her medical history is significant for an 8-year history of non-small-cell lung cancer, for which she has been treated with osimertinib for 4 years. OBSERVATIONS: An incidental finding of bilateral benign hyperpigmentation of the conjunctiva and corneal epithelium was noted in an Asian woman in her sixth decade. Pigmentation involved the caruncle and extended to the lid margins in both eyes. Her medical history is significant for an 8-year history of non-small-cell lung cancer, for which she has been treated with osimertinib for 4 years. CONCLUSIONS AND IMPORTANCE: Although rare, recognizing osimertinib-associated hyperpigmentation is clinically important as it needs to be differentiated from primary acquired melanosis, which carries a risk of progression to conjunctival melanoma.
PURPOSE: To determine the outcomes of Descemet stripping endothelial keratoplasty (DSEK) in eyes with anterior chamber intraocular lenses (ACIOLs). METHODS: Retrospective chart review of DSEK procedures in eyes with ACIO...PURPOSE: To determine the outcomes of Descemet stripping endothelial keratoplasty (DSEK) in eyes with anterior chamber intraocular lenses (ACIOLs). METHODS: Retrospective chart review of DSEK procedures in eyes with ACIOLs from May 2006 to December 2024 and posterior chamber intraocular lenses (PCIOLs) from May 2006 to July 2020 (control group). Cox analysis of risk factors for secondary graft failure (SGF) was performed. RESULTS: A total of 132 and 608 DSEK procedures were performed in ACIOL and PCIOL groups with a median follow-up of 21.7 and 36.8 months, respectively (P < 0.01). There were no significant differences between the groups in the mean VA improvement, or incidence of primary graft failure, graft dislocation, endothelial rejection, or postop intraocular pressure elevation, although glaucoma surgery was more common in the ACIOL group (14.4% vs. 6.7%, P < 0.01). The incidences of SGF in the ACIOL and PCIOL groups were 0.14 and 0.13 per eye-year (P = 0.47) and 0.11 and 0.01 per eye-year (P < 0.01) in eyes with and without glaucoma, respectively. An ACIOL increased the risk of SGF in eyes without glaucoma [hazard ratio (HR): 6.5 (2-21.4)], with a trend toward significance in eyes with medically treated glaucoma [HR: 1.9 (0.8-4.7)] but not in eyes with prior glaucoma surgery. Prior graft failure [HR: 1.8 (1.2-2.7)] and endothelial rejection [HR: 2.2 (1.2-3.3)] also increased the risk of SGF. CONCLUSIONS: An ACIOL increases the risk of SGF after DSEK in eyes without glaucoma but not in eyes with prior glaucoma surgery. Therefore, IOL exchange should be considered before DSEK in eyes with an ACIOL and without prior glaucoma surgery.
PURPOSE: To verify an objective functional test of corneal sensitivity for detection of diabetes peripheral neuropathy (DPN) in human subjects with type 2 diabetes. METHODS: Ratio of time that the eyelids were closed ove...PURPOSE: To verify an objective functional test of corneal sensitivity for detection of diabetes peripheral neuropathy (DPN) in human subjects with type 2 diabetes. METHODS: Ratio of time that the eyelids were closed over 50 seconds (10-60 seconds postinstillation) after application of isotonic versus 5% NaCl (hypertonic) solution were quantified using a video-based image analysis program. RESULTS: We examined 14 subjects with DPN and 8 controls. DPN was verified using multiple screening methods. Eye discomfort was examined by completing Dry Eye (DEQ5) and Ocular Surface Disease Index questionnaires. Cochet-Bonnet filament esthesiometer examination revealed significant corneal mechanical sensitivity impairment in subjects with DPN versus control. Corneas of patients with DPN showed significantly less chemical sensitivity versus controls to application of hypertonic solution (controls: 0.232 ± 0.039 vs. DPN: 0.159 ± 0.054; P = 0.0019; Cohen d = 1.46). Sensitivity to the isotonic NaCl solution was not significantly different between groups (P = 0.28). Receiver operator characteristic curves showed an area under the curve of 0.90 (95% CI: 0.75-1.00) for 5% NaCl chemical sensitivity and 0.75 (95% CI: 0.60-0.91) for Cochet-Bonnet mechanical sensitivity for differentiating normal subjects from patients with DPN. CONCLUSIONS: This pilot study demonstrates that clinical video-based objective evaluation of the chemical sensitivity of the corneal nerves may provide a valuable method for noninvasive detection of DPN. This test offers advantages of objectivity and biological specificity for epithelial-penetrating C-fiber nerve endings. Validation in larger, more diverse cohorts and development of automated smartphone-based implementations are needed before clinical translation.
PURPOSE: The American Society of Cornea and Refractive Surgery Cornea Committee convened to create a brief review of the literature and expert experience of antibody-drug conjugates (ADCs) and their impact on ocular surf...PURPOSE: The American Society of Cornea and Refractive Surgery Cornea Committee convened to create a brief review of the literature and expert experience of antibody-drug conjugates (ADCs) and their impact on ocular surface health. METHODS: Peer-reviewed publications from 2003 to 2025 were evaluated. The information along with authors clinical experience was used to create a white paper on the current aspects ADC therapy that is relevant to the ocular surface health. RESULTS: There are currently 14 Food and Drug Administration-approved ADCs. By most recent estimates in the literature, there are more than 200 ADCs currently in development, and a significant proportion of them are associated with keratopathy that has unique ocular surface manifestations. Features of ADC-induced keratopathy include corneal pseudocysts, superficial punctate keratitis, refractive shifts, and conjunctival hyperemia. More severe adverse events such as conjunctival hemorrhage, conjunctival scarring, and corneal ulcers are rare. These findings correlate with change in visual acuity and visual quality. Eye care providers need guidance to recognize, understand, and communicate critical features of vision health with referring oncologists. CONCLUSIONS: Given the anticipated surge in oncology patients on ADCs, there is a need for dissemination of information on ocular surface concerns. This review covers key aspects ADC toxicity mechanisms and pathological features on the ocular surface health including strategies to diagnose, grade, and treat disease. It also provides expectations on the eye care provider's role in communication with referring oncologists.
PURPOSE: To review recent advances in the diagnosis and management of acanthamoeba keratitis (AK), emphasizing clinically relevant developments from the past 5 years. METHODS: A scoping review of PubMed and ClinicalTrial...PURPOSE: To review recent advances in the diagnosis and management of acanthamoeba keratitis (AK), emphasizing clinically relevant developments from the past 5 years. METHODS: A scoping review of PubMed and ClinicalTrials.gov was conducted for studies published between July 2020 and December 2025 using the terms "acanthamoeba AND (diag* OR test* OR treatment)." Clinical studies and studies of human AK specimens were prioritized. A total of 814 publications and 11 clinical trial listings were screened, with 128 full-text articles reviewed. RESULTS: Recent diagnostic advances included artificial intelligence models developed for in vivo confocal microscopy images and anterior segment photographs. Polymerase chain reaction (PCR) assays demonstrated sensitivity similar to or greater than culture while maintaining high specificity. Emerging modalities included next-generation sequencing, viability PCR assays, and antibody-based diagnostics. Recent studies on acanthamoeba treatment include the Orphan Drug for Acanthamoeba Keratitis (ODAK) trial, which randomized eyes to polyhexamethylene biguanide (PHMB) 0.08% monotherapy or PHMB 0.02% plus propamidine 0.1% combination therapy, and found similar 12-month cure rates and visual outcomes in the two groups, and better-than-expected outcomes using a standardized protocol. Adjunctive therapies including topical voriconazole, Rose Bengal Photodynamic Antimicrobial Therapy, miltefosine, and povidone-iodine showed potential benefit, although evidence was limited primarily to observational studies and small clinical trials. Surgical management strategies, including penetrating and lamellar keratoplasty, demonstrated variable recurrence rates, and the optimal timing of keratoplasty remains uncertain. CONCLUSIONS: New diagnostic technologies and standardized PHMB-based treatment protocols may improve outcomes for AK. Evidence is more limited for a range of other potential therapies.
PURPOSE: To describe the first reported case of neurotrophic keratitis (NK) associated with telisotuzumab vedotin (Teliso-V), a c-MET-targeted antibody-drug conjugate (ADC) approved for metastatic non-small cell lung can...PURPOSE: To describe the first reported case of neurotrophic keratitis (NK) associated with telisotuzumab vedotin (Teliso-V), a c-MET-targeted antibody-drug conjugate (ADC) approved for metastatic non-small cell lung cancer (NSCLC). CASE REPORT: A 56-year-old woman with metastatic NSCLC developed bilateral, painless blurred vision approximately 10 weeks after initiating Teliso-V therapy. Initial findings of punctate keratopathy progressed to bilateral persistent corneal epithelial defects despite treatment with topical corticosteroids, preservative-free artificial tears, bandage contact lenses, prophylactic antibiotics, and amniotic membrane transplantation. Corneal esthesiometry demonstrated markedly reduced corneal sensation bilaterally, consistent with NK. Concurrent Grade 1 peripheral neuropathy also developed. Teliso-V was discontinued because of ocular toxicity. Following initiation of topical cenegermin 0.002% six times daily, epithelial defects resolved within one week in the left eye and three weeks in the right eye, with recovery of best-corrected visual acuity to 20/20 in both eyes and partial improvement in corneal sensation. No recurrence was observed six weeks after completion of therapy. CONCLUSIONS AND IMPORTANCE: This report describes the first documented case of NK associated with Teliso-V therapy. The temporal association between Teliso-V exposure, bilateral corneal hypoesthesia, persistent epithelial defects, and concurrent peripheral neuropathy suggests a potential neurotoxic mechanism related to the drug's monomethyl auristatin E payload. Clinicians should maintain a high index of suspicion for NK in patients receiving ADCs who present with painless visual decline and corneal epithelial disease. Early diagnosis and prompt treatment with cenegermin may facilitate corneal healing and prevent vision-threatening complications.
PURPOSE: To analyze how postoperative outcomes of manual deep anterior lamellar keratoplasty (mDALK) in eyes affected by keratoconus are influenced by the residual stromal thickness (RST) of the recipient. METHODS: Retro...PURPOSE: To analyze how postoperative outcomes of manual deep anterior lamellar keratoplasty (mDALK) in eyes affected by keratoconus are influenced by the residual stromal thickness (RST) of the recipient. METHODS: Retrospective interventional case series. Patients underwent DALK between 2011 and 2025 at "Magna Graecia" University of Catanzaro, Italy. Big-bubble DALK was the favorite stromal dissection technique, whereas mDALK was reserved as backup strategy. Best spectacle-corrected visual acuity (BSCVA) and tomographic parameters were evaluated preoperatively (T0) and postoperatively after complete suture removal (1 year, T2). RST was assessed 1 month postoperatively (T1) using the CASIA SS-1000 anterior-segment optical coherence tomography (Tomey, Nagoya, Japan). Measurements were performed at the center of the cornea and at 12 paracentral points along 6 different meridians equally spaced at 30 degrees. RESULTS: In total, 288 eyes underwent DALK. Of these, 234 (81.3%) underwent successful pneumatic or viscoelastic dissection, whereas 54 (18.7%) required mDALK. In this subgroup, a significant correlation was found between postoperative BSCVA and central RST [56.17 ± 15.43 μm (95% confidence interval: 52.06-60.29); ρ = 0.397, P = 0.003], but not with paracentral RST [66.75 ± 22.54 μm (95% confidence interval: 60.74-72.76); ρ = 0.24, P = 0.07]. CONCLUSIONS: Central RST presented a low-moderate yet significant correlation with postoperative BSCVA at 1 year. Corneal surgeons should aim to minimize RST compatibly with a safe stromal dissection.
PURPOSE: Allergic eye disease (AED) can be mild, moderate, or severe and have varying chronicity. Although milder disease is easier to treat, persistent refractory cases can be a challenge. Allergen-specific immunotherap...PURPOSE: Allergic eye disease (AED) can be mild, moderate, or severe and have varying chronicity. Although milder disease is easier to treat, persistent refractory cases can be a challenge. Allergen-specific immunotherapy (AIT) has been explored in treating refractory cases, especially in those with systemic associations. The purpose of this study was to assess the indications and outcomes of AIT in refractory AED. METHODS: The clinical details of patients with AED were retrospectively obtained. Cases that had exacerbations despite maximum topical therapy were termed refractory. Refractory cases were referred to the allergy specialist for evaluation and management. Based on the results of allergen testing and clinical history, allergen immunotherapy was administered as per standard guidelines. The outcomes of treatment for reduction in steroid usage and episodes of allergy were studied. RESULTS: A total of 805 patients with AED were included. Of these, 121 with refractory AED were referred to the allergy specialist. After allergen testing (skin prick test), 52 patients were started on AIT. Ninety percent patients experienced a reduction in allergy symptoms. There was a significant reduction in topical and oral steroid requirement after AIT (P < 0.01). Only 15 patients required potent topical steroid post-AIT compared with 32 before (P < 0.05). Long-term follow-up of these patients (mean duration 25.5 months) showed good allergy control with minimal side effects. CONCLUSIONS: AIT can be an useful addition to our armamentarium in cases of refractory AED and a safe option in the long term.
PURPOSE: Limbal corneal dermoids might invade the cornea at various depths, ranging from superficial lesions on the epithelium to deep lesions penetrating the entire corneal thickness and adjacent sclera. The aim of this...PURPOSE: Limbal corneal dermoids might invade the cornea at various depths, ranging from superficial lesions on the epithelium to deep lesions penetrating the entire corneal thickness and adjacent sclera. The aim of this report was to describe a limbal corneal dermoid with scleral ectasia at the posterior margin, requiring more complex surgical procedures. METHODS: Ultrasound biomicroscopy (UBM) examination was used to identify posterior scleral ectasia and ciliary body prolapse; corneal limbal dermoid was treated with excision and eccentric anterior lamellar keratoplasty (ALK). RESULTS: A 28-year-old woman presents with a limbal corneal dermoid in her left eye. It has been growing since her birth, and recently, it became more prominent. Her best-corrected visual acuity was 20/70, and there was an amelanotic vascularized yellowish limbal lesion superotemporally, measuring 14 × 14 × 4.2 mm. The cornea was involved between the 12 and 3 o'clock meridians with surrounding scarring. An intralesional cavity-like area with possible intraocular communication through a scleral break was detected by UBM. During the surgery, a scleral protrusion, indicating significant thinning of the sclera, was noted. Excision of the lesion and eccentric ALK were performed. After 51 months of follow-up, best-corrected visual acuity was 20/60; there was residual corneal scarring superonasally on examination. CONCLUSIONS: This case highlights the potential utility of UBM in identifying associated congenital abnormalities in the limbal corneal dermoid, and combined excision and reconstruction with eccentric ALK may be considered a potential surgical approach.
PURPOSE: To explore if intracameral melphalan can be used as an adjunct treatment for epithelial downgrowth. METHODS: This was a retrospective, noncomparative interventional case series. The main outcome measure was the...PURPOSE: To explore if intracameral melphalan can be used as an adjunct treatment for epithelial downgrowth. METHODS: This was a retrospective, noncomparative interventional case series. The main outcome measure was the resolution of epithelial downgrowth. Secondary measures of interest included best-corrected visual acuity (BCVA) and intraocular pressure (IOP), along with epithelial downgrowth recurrence, adverse effects, and need for repeat corneal grafts. RESULTS: All 4 cases did not experience epithelial downgrowth recurrence after melphalan administration in the subsequent 3 years. One case developed a recurrence at 42 months after melphalan administration, thought to be because of a separate inciting event. The BCVA was stable or improved at the last follow-up appointment for most cases. All cases required management for elevated IOP. Three cases required repeat corneal grafting for corneal decompensation. CONCLUSIONS: Intracameral melphalan is a viable alternative in the management of epithelial downgrowth. However, clinicians using melphalan must monitor for potential adverse effects including elevated IOP, corneal decompensation, and retinal toxicity, particularly in unicameral eyes. Future studies into melphalan or other adjunct medical treatments should involve a standardized approach with gonioscopy and endothelial cell count monitoring.
PURPOSE: To characterize age-related variations in symptomatic meibomian gland dysfunction (MGD) clinical manifestations. METHODS: This cross-sectional, hospital-based study included 100 symptomatic Asian MGD individuals...PURPOSE: To characterize age-related variations in symptomatic meibomian gland dysfunction (MGD) clinical manifestations. METHODS: This cross-sectional, hospital-based study included 100 symptomatic Asian MGD individuals (age 20-89 years). Clinical assessments included the Standard Patient Evaluation of Eye Dryness questionnaire, fluorescein tear film break-up time, corneal staining, Schirmer I test without anesthesia, lid margin examination, meibum expressibility, and quality. Interferometry was used to measure lipid layer thickness (LLT), capture blinking patterns, and obtain meibography images, which were analyzed using ImageJ software. Age was analyzed as a continuous variable using linear regression and decade-based comparisons. RESULTS: In symptomatic MGD, younger individuals correlated with more incomplete blinking, reduced LLT, and greater gland distortion (all P < 0.05). Increasing age was positively associated with LLT, meibomian gland (MG) plugging, anterior displacement of the mucocutaneous junction, telangiectasia, MG dropout area, and gland shortening and dropout (all P < 0.05). Multivariate analysis confirmed younger age and absence of MG plugging as independent predictors of reduced LLT. Decade-based analysis confirmed a significant monotonic increase in LLT with advancing age (Jonckheere-Terpstra P < 0.001). CONCLUSIONS: Symptomatic MGD presentations differ with age. Younger patients exhibit incomplete blinking and gland tortuosity with reduced LLT; older patients show lid margin changes with MG dropout and shortening. The paradoxical increase in LLT with age reflects obstructive and compensatory mechanisms rather than improved tear film function, underscoring the need for a multidimensional diagnostic approach incorporating age, MG morphology, and clinical context.
PURPOSE: To evaluate visual acuity, refractive outcomes, central corneal thickness (CCT), and safety after femtosecond laser-assisted lamellar keratectomy (FLK) for granular corneal dystrophy (GCD). METHODS: This retrosp...PURPOSE: To evaluate visual acuity, refractive outcomes, central corneal thickness (CCT), and safety after femtosecond laser-assisted lamellar keratectomy (FLK) for granular corneal dystrophy (GCD). METHODS: This retrospective study included patients with GCD who underwent FLK between January 2013 and December 2025. FLK was performed using a planned flap thickness of 120 μm and diameter of 7.5 mm, followed by intraoperative mitomycin C 0.02% for 1 minute. Best-corrected visual acuity (BCVA), refractive outcomes, and CCT were analyzed in patients with ≥30 days of follow-up. Linear mixed-effects models were used to account for intereye correlation. RESULTS: Twenty-eight eyes of 18 patients (mean age 51.5 years, 9 female, 9 male) met inclusion criteria. Ten patients underwent bilateral FLK (20 eyes). Mean BCVA improved from 0.37 logMAR preoperatively to 0.27 logMAR postoperatively (P = 3.89 × 10-4). Mean sphere changed from +0.30 ± 2.22 diopters to 0.62 ± 2.24 diopters (P = 0.21), and mean cylinder changed from -1.39 ± 0.90 diopters to -1.04 ± 0.86 diopters (P = 0.10). Mean CCT decreased from 517.5 to 438.4 μm (P = 8.77 × 10-6). No intraoperative or postoperative complications were observed. CONCLUSIONS: FLK for GCD was associated with significant improvement in BCVA, nonsignificant and minimal refractive change, and a mean CCT reduction of 83.9 μm.