Standing superficial keratectomy provides long-term control of epithelial and stromal equine immune-mediated keratitis.

To describe the corneal in vivo confocal microscopy (IVCM) findings in horses with putative immune-mediated keratitis (IMMK). Sixty five horses with IMMK. Horses diagnosed with IMMK were examined with a modified Heidelberg Retina Tomograph II and Rostock Cornea Module. The findings from the IVCM examinations were correlated with clinical details from ophthalmic examination and diagnostic test results. Eighty eyes from 65 horses were examined. Clinical IMMK lesions were categorized as epithelial (n=17 eyes), superficial stromal (n=38), midstromal (n=18), and endothelial (n=7). Epithelial, superficial stromal, and midstromal lesions were characterized with IVCM by variable corneal leukocyte infiltrates and vascularization of the approximate corneal anatomic region that was clinically affected as determined by biomicroscopy. In addition, all horses displayed a dense network of dendritic cells in the epithelial basement membrane and immediate subepithelial stroma. Less consistent IVCM findings included epithelial disorganization, corneal edema, mineral deposition, stromal fibrosis, and epithelial pigment granules. Endothelial IMMK was distinct from the other forms of IMMK and characterized with IVCM by stromal edema, endothelium disorganization, endothelial cell loss, and multifocal accumulations of highly reflective material within the endothelium. The distinguishing feature of epithelial and stromal forms of IMMK is a dense accumulation of dendritic cells in the epithelial basement membrane and immediate subepithelial stroma. Cellular changes in endothelial IMMK were largely confined to the endothelium and distinct from the other forms of IMMK evaluated.

Use of photodynamic therapy (PDT) for the treatment of immune-mediated keratitis (IMMK) in horses is becoming common. The safety and morphologic impact on the normal equine cornea have not been investigated, and the mechanism of its efficacy is unknown. To investigate the morphologic effects and safety of in vivo PDT on healthy equine corneas. In vivo experiment. Six university-owned horses underwent unilateral corneal PDT with intrastromal infracyanine green (EmunDo®) and photoactivation with an 810 nm diode laser (500 mW for 2.5 min = 75 Joules). Complete ophthalmic examinations, clinical scoring, digital and infrared photography, ocular thermography, in vivo confocal microscopy (IVCM), and ultrasound biomicroscopy were performed pre-treatment and post-treatment on study days 1, 5, 15, 33, and 103. Post-treatment, corneal ulceration occurred in all treated eyes. In all horses, IVCM identified destroyed keratocytes immediately post-treatment followed by keratocyte depopulation on days 5 and 15. Slow keratocyte repopulation was evident on days 33 and 103. Stromal keratitis was seen on day 5 and persisted through day 103. EmunDo® remained visible in the cornea on study day 103 in 5/6 horses. No horses developed blinding complications. Limited sample size included horses of various ages. Corneal ulceration, keratocyte depopulation, prolonged stromal keratitis, and prolonged corneal dye retention occurs with PDT in normal equine corneas. Corneal stromal cellular depopulation is proposed as the mechanism by which PDT is effective in the treatment of equine IMMK.

Purpose During body screening of melanocytic lesions, naevi of the eyelids, conjunctiva and caruncula, although accessible to the dermatologist, are often missed out. These tumors have similar characteristics and prognosis as oral or genital ones. We report the first cases of caruncular naevi observed by in vivo confocal microscopy (IVCM).Methods Five patients, 4 men and 1 woman, who presented with a caruncular melanocytic lesion, were examined by IVCM, using the handheld dermatological IVCM Vivascope 3000 (Lucid Inc, NY, MAVIG GmbH, Germany) equipped with 830nm class IB laser.Results Mean age was 39 years old (25‐71). The tumors which were 2.2mm width on average (0.5 ‐ 3.0 mm) were present since 4 years on average (1‐10). Two patients had family history of skin melanoma. IVCM showed hyperreflective round cells that were either isolated or grouped within the lamina propria. No abnormal cells were observed. Despite the benign IVCM aspect, a surgical excision biopsy was performed on 4 patients, for definitive histopathology or esthetic reasons. All 4 were compound naevus on histopathology. The remaining patient had no progression at 6 months follow upConclusion The caruncular site is inaccessible to both dermatoscopic imaging and standard dedicated ophthalmological IVCM. The Vivascope 3000 overpass this site limitation thanks to the small head of the camera and its handy and portable dimensions. In all cases, the IVCM imaging correlated with histopathology. This is the first reported series of caruncular melanocytic lesions explored in IVCM. Grant: GIRCI Rhone Alpes Auvergne 2012

Monitoring the Inflammatory Process in Herpetic Stromal Keratitis: The Role of In Vivo Confocal Microscopy

Purpose: Introducing a simple image grading system to support the interpretation of in vivo confocal microscopy (IVCM) images in filamentous fungal keratitis. Setting: Clinical and confocal studies took place at the Department of Ophthalmology, Aarhus University Hospital, Denmark. Histopathological analysis was performed at the Eye Pathology Institute, Department of Neuroscience and Pharmacology, University of Copenhagen, Denmark. Methods: A recent series of consecutive patients with filamentous fungal keratitis is presented to demonstrate the results from in-house IVCM. Based upon our experience with IVCM and previously published images, we composed a grading system for interpreting IVCM images of filamentous fungal keratitis. Results: A recent case series of filamentous fungal keratitis from 2011 to 2012 was examined. There were 3 male and 3 female patients. Mean age was 44.5 years (range 12-69), 6 out of 17 (35%) cultures were positive and a total of 6/7 (86%) IVCM scans were positive. Three different categories of IVCM results for the grading of diagnostic certainty were formed. Conclusion: IVCM is a valuable tool for diagnosing filamentous fungal keratitis. In order to improve the reliability of IVCM, we suggest implementing a simple and clinically applicable grading system for aiding the interpretation of IVCM images of filamentous fungal keratitis.

Corneal opacities rarely occur in multiple myeloma (MM). Our study correlates the findings of in vivo confocal microscopy (IVCM), a useful diagnostic tool, with histopathological features of corneal opacities appearing in a patient with MM. Case report. A 53-year-old man developed corneal opacities in both eyes, more pronounced in the left eye. After IVCM examination, he underwent penetrating keratoplasty in the left eye, and the button was processed for light and electron microscopy and immunohistochemistry. The diagnosis of MM was made, as confirmed by the elevation of IgGk light chains. IVCM demonstrated hyperreflective areas at the epithelial level, hyperreflective keratocytes of dendritic and lamellar morphology in whole stroma, and hyperreflective endothelial cells. Histopathological examination disclosed many vacuoles in the epithelial cell cytoplasm and a homogenous granular material in the Bowman layer. In stroma, keratocytes of different shape and size, with vesicles laden with an abnormal material, were evident. In Descemet membrane, the posterior nonbanded zone had a honeycomb appearance because of the presence of many roundish spaces among wide-spaced collagen fibers. Endothelial cells demonstrated vesicles filled with a material of uneven electron density. Immunohistochemical analysis showed strong positivity for IgGk light chains in keratocytes and among stromal lamellae. This is the first study describing a correspondence between IVCM features and histopathological alterations observed in corneal opacities in MM. The results of this study improve the current understanding of the pictures obtained by IVCM studies.

Objective: To identify and analyze imaging features of posterior polymorphous corneal dystrophy (PPCD) by in vivo confocal microscopy (IVCM). Methods: This retrospective case series enrolled 27 eyes of 18 patients (including 10 males and 8 females) who were diagnosed with PPCD at the Department of Ophthalmology in Peking University Third Hospital between January 2013 and December 2019. The mean age was (23.61±14.81) years. There were 9 monocular and 9 binocular cases. All patients were examined by slit-lamp biomicroscopy and IVCM. The visual acuity, the mean endothelial cell density, and the images of IVCM were analyzed in all cases. Results: The mean best-corrected visual acuity was 0.76±0.33, and the mean endothelial cell density was (1 723.6±698.3) cells/mm2. The IVCM images of type 1 PPCD (vesicular lesions) showed hyperreflective, placoid or homocentric lesions at the level of the Descemet's membrane, hyporeflective, oval or round lesions at the level of the Descemet's membrane, and hyporeflective, crater-like lesions at the level of the endothelial cell layer. The IVCM images of type 2 PPCD (band lesions) displayed hyperreflective, band lesions and a fibrous strand structure at the level of the Descemet's membrane, hyporeflective, vesicular lesions at the level of the Descemet's membrane, and hyporeflective, trough-and ridge-like lesions at the level of the endothelial cell layer. The IVCM images of type 3 PPCD (geographic placoid opacities) showed loss of the hexagonal features of endothelial cells and epithelial-like cell transformation. Conclusions: PPCD primarily affects the endothelium and Descemet's membrane. IVCM could highlight the special characteristics of PPCD including hyperreflective lesions at the level of the Descemet's membrane, hyporeflective lesions at the level of the endothelial cell layer, and epithelial-like cell transformation of endothelial cells. IVCM is an invaluable tool for clinical diagnosis and dynamic monitoring of PPCD.

To investigate the characteristics of in vitro culture and in vivo confocal microscopy (IVCM) in patients with fungal keratitis (FK) presented in a tertiary referral hospital in central China. In this noncomparative retrospective study, patients with the diagnosis of FK between October 2021 and November 2022 were reviewed. An IVCM and fungal culture (corneal scraping specimens) were performed, and the characteristics were analyzed. During October 2021 and November 2022, 85 patients were diagnosed with FK. From 63 culture-positive cases, 8 species of fungus were identified. The proportions of isolated fungal species were Fusarium and Aspergillus equally accounting for 33.3% (21 of 63), Alternaria 9.5% (6 of 63), Curvularia 6.3% (4 of 63), Scedosporium apiospermum 6.3% (4 of 63), Paecilomyces lilacinus 3.2% (2 of 63), Exserohilum 3.2% (2 of 63), and Candida 4.8% (3 of 63), respectively. In positive culture cases, IVCM was found to be positive for hyphae or spores in 61 of 63 patients (96.8%). Different fungal species had a variety of cultural characteristics and IVCM manifestations. In a tertiary referral hospital in central China, Fusarium species, Aspergillus species, and Alternaria species were the 3 most common isolated fungal pathogens, and the proportion of Aspergillus species was significantly higher than that in other regions of China. Careful lesion depth examination by IVCM and OCT should be taken before lamellar keratoplasty to avoid postoperative recurrence. Identifying the IVCM image and culture characteristics will facilitate rapid diagnosis and proper treatment, but IVCM cannot yet replace fungal cultures to distinguish between different fungal species.

Pyrenochaeta unguis-hominis, also known as Neocucurbitaria unguis-hominis, is a rare fungal pathogen typically isolated from skin and nail infections. Recently, it has been identified as a cause of fungal keratitis, particularly among contact lens wearers. This case report documents the occurrence of Pyrenochaeta unguis-hominis keratitis in Austria and the visualization of changes in the corneal stroma using in vivo confocal microscopy (IVCM). A 48-year-old female patient presented with severe photophobia and acute pain in her left eye, following extended wear of soft contact lenses. Initial examination revealed a central corneal infiltrate. IVCM was performed prior to corneal scraping, which was then sent for direct staining, culture, and next-generation sequencing (NGS) and identified Pyrenochaeta unguis-hominis and Streptococcus oralis. Treatment included hourly topical voriconazole 2%, natamycin 5% and vancomycin 2.5%, with additional epithelial debridement to enhance drug penetration. IVCM imaging allowed for real-time visualization and tracking of structures with the appearance of fungal hyphae, guiding the treatment course. Over several months, IVCM demonstrated a reduction in these structures, and the patient's condition stabilized, resulting in improved corneal clarity and Best Corrected Distance Visual Acuity from 0.8 to 0.9 (Snellen decimal scale). This case contributes to the limited clinical literature on Pyrenochaeta unguis-hominis-associated keratitis and includes IVCM imaging of a cornea with this rare infection. While IVCM provided early, non-invasive visualization of stromal changes, definitive diagnosis was achieved through molecular testing. A conservative treatment regimen with topical antifungals and epithelial debridement was effective, emphasizing the importance of rapid diagnostics and targeted therapy in managing rare corneal infections.

Aim The comparison of the diagnostic efficiency of a reference method (light microscopy [LM] using 10% potassium hydroxide [KOH]) with the use of 100% alcohol to in vivo confocal microscopy (IVCM) for the detection of Demodex eyelid infestation in seborrheic blepharitis patients. Methods Eyelashes were epilated from the right eyes for the reference method and the left eyes for the alcohol group in 58 eyes of 29 patients. IVCM was used on the left eyes. The primary outcomes were the number of Demodex mites per lash and the rate of Demodex positivity (≥1 mite). Results The rate of Demodex positivity was similar among the three groups (KOH: 82.8%, alcohol: 86.2%, IVCM: 72.4%; p >.05). The mean number of mites per lash in the KOH group (1.5 ± 1.3) was higher than in the alcohol (0.9 ± 0.6, p =.041) and IVCM groups (0.9 ± 0.9, p =.036). Conclusion KOH was found to be superior in terms of the quantification of mites compared to alcohol and IVCM.

Objectives:To analyze and assess compatibility of trabeculectomy filtering bleb characteristics and appearances using biomicroscopy, anterior segment optical coherence tomography (AS-OCT) and in vivo confocal microscopy (IVCM).Materials and Methods:Twenty-eight eyes of 28 patients who underwent glaucoma filtering surgery with mitomycin C in our clinic between 2009 and 2013 were evaluated. Morphological appearances of the blebs on slit-lamp biomicroscopy were defined according to the Moorfields bleb classification system. For the internal tissue assessment of blebs, AS-OCT and IVCM were performed. Bleb biometric parameters such as length, height and bleb wall thickness were assessed by AS-OCT; conjunctival epithelial-stromal cyst, structural network of conjunctival stroma and vascularisation were examined with IVCM. The relation between biomicroscopic morphological staging and bleb characteristics detected on AS-OCT and IVCM were assessed.Results:The mean age of the 28 patients (16 male, 12 female) was 57.2±15.9 (19 to 79) years. The mean time elapsed between surgery and examination was 29.2±19.2 (6 to 68) months. According to biomicroscopic appearance, 17 (60.7%) blebs were functional (13 diffuse, 4 microcystic), whereas 11 (39.3%) blebs were non-functional (9 flat, 2 encapsulated). In the comparison of non-functional and functional blebs, functional blebs were found to be superior in terms of biometric parameters on AS-OCT assessment (p<0.05). Higher number of epithelial and stromal cysts and less vascularisation were detected by IVCM in functional blebs when compared with non-functional blebs (p<0.05).Conclusion:Biomicroscopic appearances and characteristics on AS-OCT and IVCM of filtration blebs are consistent with each other. Besides biomicroscopic examination, which is an easy and practical method for determining bleb morphology, cross-sectional images obtained by AS-OCT and IVCM provide objective data regarding internal structure and functional features of blebs.

Acanthamoeba keratitis (AK) is a severe eye infection that can cause severe vision loss, especially in contact lens wearers. Rapid and accurate diagnosis is crucial for achieving favorable outcomes. Traditional methods, such as culture, are slow and have variable sensitivity, while molecular techniques offer improved detection. This study evaluated nested polymerase chain reaction (PCR) targeting the 18S ribosomal RNA (rRNA) gene for rapid AK diagnosis, comparing its performance to one-step PCR, culture, and in vivo confocal microscopy (IVCM). This study included 42 suspected AK patients who underwent IVCM and corneal scraping for culture, PCR, and nested PCR. AK diagnosis was confirmed based on clinical findings, risk factors, treatment response, and at least one positive diagnostic test. Out of 42 patients, 27 were positive for Acanthamoeba with at least one of the diagnostic methods. Based on the diagnosis of definite AK, the sensitivity of IVCM, culture, PCR, and nested PCR was 77.78%, 37.04%, 62.96%, and 96.3%, respectively. The specificity and positive predictive values were 100% for all the tests. The negative predictive values of IVCM, culture, PCR, and nested PCR were 71.43%, 46.88%, 60%, and 93.75%, respectively. Nested PCR results displayed the highest agreement with IVCM. In conclusion, nested PCR enhances AK detection compared to conventional methods, improving sensitivity in low corneal scrape quantities. Combining high-sensitivity tests increases diagnostic accuracy, and nested PCR with IVCM is the most effective approach. When IVCM is unavailable, nested PCR serves as a reliable diagnostic tool, especially when culture and one-step PCR yield negative results.

Purpose To report the in vivo and ex vivo histopathologic features of the cornea in a patient with endothelial decompensation within the scope of multiple sclerosis (MS). Methods During a 2‐year period a 64‐year‐old male patient, suffering from multiple sclerosis and unilateral bullous keratopathy, was repeatedly examined by slit‐lamp and in vivo confocal microscopy (IVCM). Light microscopy with histochemical staining, transmission electron microscopy (TEM), and scanning electron microscopy (SEM) were performed on the corneal button obtained at penetrating keratoplasty. Results Besides corneal decompensation on his left eye, slit‐lamp examination of both eyes showed a deposition of translucent vesicles on the iris and fine deposits on the corneal endothelium and anterior lens pole. Observation of the endothelium by IVCM confirmed fine precipitates in the right eye, and displayed larger deposits in the left eye. After further deterioration, the left eye showed endothelial denudation. Light microscopy of the corneal button showed periodic acid‐Shiff and Giemsa positive granular deposits in the epithelium and stroma. The same electron dense deposits displayed a fingerprint configuration with TEM. This finding corresponds with a deposition of neurodegenerative origin. SEM disclosed similar unique morphological changes of the endothelial cells as detected by IVCM. Lichen‐like deposits were observed on the endothelial cells. Conclusion IVCM enabled us to obtain high resolution images of the endothelial layer in an obscured cornea. This resulted in the discovery of a new ocular manifestation of multiple sclerosis.

Objectives:The objectives of the study are to show up the healing processes after anterior stromal puncture (ASP) in the cornea using in vivo confocal microscopy (IVCM) and to investigate the efficacy of ASP in the treatment of recurrent corneal erosion (RCE).Methods:This is a prospective, non-randomized, consecutive series. Twenty-three eyes of 19 patients diagnosed with RCE were evaluated between March 2020 and January 2022. Outcome measures included age, sex, laterality, etiology of RCE, duration and recurrence of symptoms, additional treatments required, and complications. IVCM was performed on the same day, at 1st week, 1st, and 6th month.Results:Mean age was 41.5±11.3 years, 63.2% of patients were female and 65.2% of eyes had unilateral involvement. Corneal trauma (56.5%) was the most common cause. Mean follow-up was 21.1 months (range 8–33). At the final follow-up, 69.5% of eyes were symptom free, 17.4% required a second ASP, and 13% needed a third ASP. At the 1st week, the epithelium became intact. An increase in activated keratocytes and dendritic cells (DCs) with beading of nerve fibers was observed. At 1st month, DCs and activated keratocytes were still present. At the 6th month, a scar was left. The superficial and basal epithelial cell formation and subbasal corneal nerve plexus returned to normal.Conclusion:IVCM has a superiority in visualizing cornea at cellular level. After ASP which is a safe, practical, and cost-effective treatment option in paracentral or peripherally located RCE, IVCM may help the surgeon to better observe and understand the post-healing processes and explain the recurrences.

Background: In vivo confocal microscopy (IVCM) provides high-resolution corneal imaging that may enhance preoperative and postoperative assessment in refractive surgery. This pilot study aimed to evaluate the diagnostic utility of IVCM in identifying subclinical corneal abnormalities that could influence surgical qualification and outcomes. Methods: A total of 7 patients (3 males, 4 females; mean age 48.8 ± 14.5 years) undergoing qualification or follow-up for refractive surgery were prospectively examined between May 2021 and March 2025. Each participant underwent a comprehensive ophthalmic evaluation, including slit-lamp biomicroscopy, corneal topography, anterior segment optical coherence tomography (AS-OCT), and IVCM using the Heidelberg Retina Tomograph II with Rostock Cornea Module. Patients with prior ocular surgery, active infection, or systemic corneal disease were excluded. Results: IVCM revealed subtle epithelial, stromal, and endothelial abnormalities undetectable by conventional methods. Findings such as Thygeson’s keratitis, pre-Descemet’s dystrophy, and subclinical herpes simplex keratitis led to modifications of surgical plans or disqualification in selected cases. The technique also aided postoperative evaluation of epithelial–stromal interface disorders. Conclusions: IVCM proved to be a valuable adjunct in detecting subclinical corneal pathology, refining patient selection, and improving safety in refractive surgery. Larger multicenter studies are warranted to validate its clinical role and define standardized indications for preoperative screening.