Anterior Stroma Research Articles

Prospective In Vivo Confocal Microscopy of the Central Cornea in Terrien Marginal Degeneration.

To analyze central corneal in vivo confocal microscopy (IVCM) in Terrien marginal degeneration (TMD). An observational prospective case-control study. Ten Finnish patients with TMD from a tertiary referral center were compared with 10 age- and sex-matched healthy volunteers. Seven patients had bilateral TMD. Age, anterior segment optical coherence tomography, extent of thinning in clock hours, grade of microdots, and stage of TMD were analyzed. According to Süveges and Wang classification, the median stage of TMD was 2 (range, 2-3) and 2 (range, 2-6), respectively. Twelve (71%) of 17 eyes with clinical TMD showed corneal thinning at all clock hours. The median age at the time of examination was 70 years (range, 28-81), and the median time from diagnosis 8.8 years (range, 6.0-15.2). By IVCM, the epithelium, subepithelial nerve plexus, and endothelium were intact in all eyes. The anterior stroma showed bilateral hyperreflective dots in the central cornea beneath the subepithelial nerve plexus in all eyes, and larger patches were detected in the posterior stroma anterior to Descemet membrane; both were invisible by anterior segment optical coherence tomography. As compared with controls, the grade of anterior microdots increased faster with age before the age of 65, and that of posterior stromal patches was higher. Two patients additionally had bilateral hyperreflective needle-like deposits in the anterior and midstroma. By IVCM, TMD is characterized regardless of clinical laterality by bilateral microdots in the central corneal stroma. They might be a supporting diagnostic criterion and alone could suggest subclinical disease.

Meibomian gland lipid alterations and ocular surface sequela in Awat2 knockout murine model of meibomian gland dysfunction and evaporative dry eye disease

PurposeThere is an urgent need for animal models of meibomian gland dysfunction (MGD) and evaporative dry eye disease (EDED) to understand their pathophysiology and investigate novel therapeutics. This study sought to further define the acyl-CoA: wax alcohol acyltransferase 2 knockout (Awat2 KO) mouse as a model of EDED using a combination of novel clinical, biochemical, and biophysical endpoints. MethodsWildtype and Awat2 KO mice between 1 and 18 months of age were used. Ocular examinations and advanced imaging were performed. The lipidomic composition and in situ melting temperature of meibum were determined. qPCR was performed to define ocular surface gene and pro-inflammatory transcript expression. Dynamic contact angle goniometry was performed to assess the adherence capability of the ocular surface. ResultsAwat2 KO mice have mild, white, hyperreflective corneal opacities of the anterior stroma and significantly enlarged apical epithelial cells (P=0.0004). In Awat2 KO meibum, wax esters were 9-10 times lower than in wildtype meibum. Additionally, meibum melting temperature increased from 32° to 47°C (P<0.0001), leading to impaired meibum secretion and dilation of the central duct. Awat2 KO corneal epithelia had significantly decreased mucin expression (Muc1 and Muc4, P=0.0043) and increased interferon-γ production (P=0.0303). Awat2 KO globes have a significantly shortened time of droplet adherence to their ocular surface (P=0.0053), indicating a decreased tear film adherence capacity. Wildtype corneal epithelia does not express Awat2, indicating that the EDED phenotype is secondary to the loss of Awat2 from the meibomian glands. ConclusionsAwat2 KO mice recapitulate many of features of human MGD and EDED, representing a model to test novel therapeutics.

Multimodal Imaging of Posterior Corneal Opacities in Multicentric Osteolysis Nodulosis and Arthropathy (MONA).

Multicentric osteolysis nodulosis and arthropathy (MONA) syndrome is a rare autosomal recessive skeletal dysplasia. Caused by mutations in the matrix metalloproteinase 2 gene (MMP2) on chromosome 16q12, this syndrome has infrequently been associated with ophthalmic manifestations. Corneal opacities have been reported but not described or documented in detail. Complete ophthalmologic examination and multimodal anterior segment imaging were used to characterize the corneal findings in a patient with MONA syndrome. A 19-year-old with MONA syndrome was referred for an eye exam based upon MONA screening recommendations. Visually insignificant peripheral corneal opacities were noted. Anterior segment optical coherence tomography (AS-OCT) demonstrated posterior stromal and endothelial hyperreflectivity. Confocal microscopy demonstrated an acellular peripheral endothelium with a normal central endothelium. Corneal opacities can occur with MONA syndrome, which is caused by mutations in the MMP2 gene. In the patient presented here, the corneal opacities are peripheral, deep stromal, with sparing of the anterior stroma and epithelium.

A review of Bowman's layer structure, function, and transplantation.

Bowman's layer is an acellular corneal structure, which is considered to be a specially modified anterior stroma. It is presumed, that it forms as a result of ongoing epithelial-stromal interactions and no clear physiological purpose has been proven. Despite this fact, Bowman's layer has found its place in corneal transplantation. It has been performed for over adecade, mainly in treatment of advanced keratoconus with multiple modifications. Transplantation of Bowman's layer can be expected to become a widely used surgical procedure in the treatment of many corneal pathologies involving fragmentation and destruction of Bowman's layer. This article aims to summarize information available on its structure, possible function, and transplantation. A thorough literature search was performed in the PubMed database and Google Scholar using keywords: Bowman's layer, structure, function, preparation and corneal transplantation. All the relevant sources were used, which represent 77 peer-reviewed articles with information corcerning the topic of this article.

Pre-Descemet Corneal Dystrophy – Changes in Corneal Morphology in Confocal Microscopy

PurposeTo identify and describe the in-vivo microstructural changes in the cornea of patients with pre-Descemet’s membrane corneal dystrophy.MethodsTen patients (20 eyes) were examined in the Laser Microsurgery Centre in Warsaw. The ophthalmic examination, including visual acuity and slit lamp biomicroscopy, was carried out. Because of suspicion of corneal dystrophy, in vivo confocal microscopy of the cornea was also performed.ResultsBiomicroscopy revealed bilateral, dust-like fine opacities in the deep parts of the corneal stroma. Confocal microscopy showed pleomorphic structures (enlarged keratocytes) containing dense, hyperreflective, granular inclusions in the posterior stroma, next to the Descemet’s membrane. In 3 patients (6 eyes) punctate particles were seen extracellularly also in the mid stroma. Superficial and basal epithelial layers, anterior stroma and endothelium cells appeared normal.Conclusions1. In vivo confocal microscopy findings of cornea with pre-Descemet’s membrane dystrophy are characteristic. 2. In vivo confocal microscopy is a useful tool in diagnosing rare corneal dystrophies in cases where classical examination methods give inconclusive results.

Influence of Opacity Depth on Big Bubble Formation During Deep Anterior Lamellar Keratoplasty in Corneal Stromal Scars.

To identify the key preoperative predictors of big bubble (BB) formation during deep anterior lamellar keratoplasty in patients with corneal stromal scars (CSS). This retrospective cohort study included consecutive patients with CSS after infective keratitis who underwent BB-deep anterior lamellar keratoplasty between January 2021 and July 2023 at a tertiary referral center. Topographic and tomographic data were collected to compare the rates and types of BB formations. Anterior segment optical coherence tomography (AS-OCT) was employed to assess the maximum depth of opacity by dividing the stroma into 3 zones of equal thickness: anterior (stage A), mid (stage B), and posterior stroma (stage C). Multivariate logistic regression analysis was performed to identify the potential preoperative predictors of bubble formation. Pneumatic dissection was achieved in 13 of 33 eyes (39.4%), with 11 BB type 1 eyes (33.3%) and 2 BB type 2 eyes (6.1%). According to AS-OCT grading, bubble formation was more frequent with CSS involving more superficial stromal layers (P <0.032). In the eyes with stage C, bubble formation failed 12 out of 14 times (85.7%, P <0.026). Spearman correlation showed that bubble formation was inversely associated with the AS-OCT grading (rho = -0.443, P = 0.001). After logistic regression analysis, AS-OCT grading was found to be the sole factor that predicted bubble formation (coeff. -1.58, confidence interval 95% -3.03 to -0.12, P = 0.034). Depth of opacity in CSS was the key determinant for predicting the success of pneumatic dissection, as advanced AS-OCT stages are strongly associated with BB failure.

Dynamic evaluation of corneal cross-linking and osmotic diffusion effects using optical coherence elastography

Dynamic deformation events induced by osmosis or photochemical stiffening substantially influence geometrical and mechanical assessments in post-mortem corneas, therefore need to be carefully monitored in experimental settings. In this study, we employed optical coherence elastography (OCE) to quantify dynamic deformation processes at high resolution in freshly enucleated porcine corneas. Osmotic effects were studied by immerging n = 9 eyes in preservation media of three different tonicities. Dynamic processes underlying corneal cross-linking (CXL) were studied by subjecting n = 6 eyes to standard Dresden treatment, while three control groups were used. The entire procedures were performed under an OCE setup during up to 80 min, acquiring a volumetric scan every 20 s. Changes in OCE-derived axial deformations were incrementally calculated between consecutive scans. Preservation conditions had a strong influence on the observed strain patterns, which were consistent with the tonicity of the medium (swelling in hypotonic, deswelling in hypertonic environment). In the CXL group, we observed deswelling of the anterior stroma 10 min after starting the UV irradiation, which was not observed in any control group (p = 0.007). The presented results proved OCE to be a valuable technique to quantify subtle dynamic biomechanical alterations in the cornea resulting from CXL and preservation solutions.

Age-related impairment in testosterone elevation after anterior fibromuscular stroma preserved enucleation.

This study aims to evaluate the impact of anterior fibromuscular stroma preserved enucleation (AFSPE) of the prostate on serum testosterone levels in patients with benign prostatic obstruction (BPO) and to explore age-related differences in postoperative testosterone elevation. In a retrospective analysis, 304 patients from a pool of 560 who underwent AFSPE at Linkou Chang Gung Memorial Hospital between January 2018 and December 2021 were evaluated. Patients were stratified based on preoperative testosterone levels into low (<3.5 ng/mL) and normal (≥3.5 ng/mL) groups. Serum testosterone levels were measured preoperatively, at 1.5 and 3-6 months postoperatively. Age and other demographic data were analyzed as potential factors influencing testosterone changes. The low-testosterone group (n = 90) showed significant testosterone increases, from an average of 2.61 ng/mL preoperatively to 3.3 ng/mL at 1.5 months and 3.59 ng/mL at 3-6 months postoperatively (p < 0.0001). The normal-testosterone group (n = 214) maintained stable testosterone levels at 1.5 months but exhibited a significant rise to 6.06 ng/mL by 3-6 months (p = 0.0079). Older age was inversely associated with postoperative testosterone elevation in both groups. Improvements in nocturia were notable in both groups. AFSPE of the prostate significantly elevates serum testosterone levels in men with BPO, particularly benefiting those initially with low levels. Age is a crucial factor influencing postoperative testosterone changes, indicating that younger patients may benefit more from this intervention. AFSPE offers a promising approach for improving hormonal health in BPO patients, alongside alleviating urinary symptoms.

Paraproteinaemic keratopathy simulating a crystalline keratopathy

BackgroundParaproteinemic keratopathy is a rare disorder characterized by the bilateral accumulation of polychromatic deposits diffusely in all corneal layers together or not with diffuse or patchy pseudo lipid deposits. We present an atypical case of paraproteinemic keratopathy which lead to an initial misdiagnosis of infectious crystalline keratopathy.Case presentationa 69-year-old woman with an asymptomatic keratopathy detected during a cataract intervention. Slit-lamp examination revealed several hyper refringent subepithelial foci with fern-shaped branches, resembling crystalline keratopathy, in her left eye. Anterior segment optical coherence tomography revealed exclusively subepithelial hyperreflective lesions limited to the anterior stroma. The progressive bilateralization and progression of the condition prompted us to include other entities with crystalline corneal deposits in our differential diagnosis. Hematological analysis showed a high number of free Kappa light chains. Despite the typical clinical appearance of crystalline keratopathy, the atypical evolution and test results led us to consider that monoclonal gammopathy could be the cause of this entity.ConclusionsParaproteinemic keratopathy may present in its early stages as a unilateral subepithelial crystalline keratopathy. Thus, it must always be taken into account in the differential diagnosis of any crystalline keratopathy, particularly when there are no predisposing factors for an infectious crystalline keratopathy. Early recognition of this rare entity is important to address the associated potentially serious systemic disease.

Anatomic Locations and Metastatic Risk in Prostate Cancer in African Men: Insights From an African Cohort.

There is significant variability in the pathogenetic characteristics of prostate cancer (PCa) across different anatomical zones. This study aims to understand the metastatic risk associated with these zonal predispositions among African men. This hospital-based retrospective observational study included 120 biopsy-confirmed PCa patients examined between 2019 and 2023. Data on cancer history, sociodemographic, and clinical characteristics were collected from medical records. A logistic regression model was used to identify predictors of metastasis. The majority of PCa lesions were found in the left (60.0%) and right peripheral zones (55.8%), followed by the left (42.5%) and right transitional zones (41.7%). Lesions in the anterior fibromuscular stroma (crude odds ratio (cOR): 3.27, 95% confidence interval (CI): 1.13-9.47; p = 0.029), central gland (cOR: 5.38, 95% CI: 1.40-20.60; p = 0.014), and diffuse infiltration involving whole gland (cOR: 6.78, 95% CI: 1.17-30.07; p = 0.032) were associated with significantly increased odds of metastasis. Lesions in the anterior fibromuscular stroma were a marginally independent predictor of metastasis (adjusted odds ratio (aOR): 28.14, 95% CI: 0.96-822.46; p = 0.053). This study underscores the variability in metastatic risk of PCa lesions across different anatomical zones in African men. Lesions in the anterior fibromuscular stroma, central gland, and diffuse infiltration involving the whole gland have higher odds of metastasis. These findings highlight the need for targeted diagnostic and therapeutic strategies based on lesion localization to improve PCa management in this population.

Recurrence Characteristics on Optical Coherence Tomography and Treatments of Reis-Bücklers Corneal Dystrophy After Phototherapeutic Keratectomy or Penetrating Keratoplasty

PurposeTo evaluate the recurrence characteristics on optical coherence tomography and clinical outcomes after phototherapeutic keratectomy (PTK) or penetrating keratoplasty (PKP) in patients with Reis-Bücklers corneal dystrophy (RBCD). DesignRetrospective interventional case series. MethodsSeventeen patients with RBCD (31 eyes, including six surgery-naïve eyes and 25 surgical eyes) received 44 surgical interventions from 1996 through 2022. PTK or PKP was performed as the initial surgical procedure. Significant recurrence was determined when best spectacle-corrected visual acuity decreased at least two lines with increased opacity in the superficial cornea. Repeated PTK or PTK on the corneal graft (CG-PTK) was considered if patients could not endure poor vision due to significant recurrence. Recurrence depth and annual increase in thickness of the central cornea and subepithelial deposits were assessed by anterior segment optical coherence tomography. ResultsThe mean follow-up time was 12.8±8.5 years (range, 2.0–25.5 years). The mean logMAR best spectacle-corrected visual acuity improved from 1.24±0.48 preoperatively to 0.27±0.09 postoperatively in the initial PTK group (13 eyes, P<0.001), from 1.84±0.69 to 0.40±0.13 in the PKP group (12 eyes, P<0.001), from 1.04±0.46 to 0.30±0.07 in the repeated PTK group (12 times in 7 eyes, P<0.001), and from 1.29±0.43 to 0.39±0.11 in the CG-PTK group (7 times in 5 eyes, P=0.001). The median significant recurrence time was 27 months (95% confidence interval 23.9-30.1), 96 months (84.1-107.9), 31 months (28.8-33.1), and 24 months (19.8-28.2), respectively (P<0.001). The depth of superficial deposits located between the epithelium and the anterior stroma was approximately 115μm (85-159μm). The annual thickening of subepithelial deposits was 14±2μm after initial PTK, 7±3μm after PKP, 14±3μm after repeated PTK, and 30±11μm after CG-PTK, compared to 4±2μm in surgery-naïve eyes (P=0.002, 0.515, 0.002, <0.001). The thickness of the central cornea increased by 15±2μm, 7±2μm, 15±3μm, and 31±10μm per year in the four surgery groups, respectively, compared to 5±2μm in surgery-naïve eyes (P=0.001, 0.469, 0.001, <0.001). ConclusionsBetter visual acuity can be achieved after PTK than PKP for treatment of RBCD. The annual thickening of subepithelial deposits may approximate an increase in central corneal thickness. The superficial distribution of subepithelial deposits makes it feasible to perform repeated PTK, even on the corneal allograft, for recurrent RBCD.

Crystalline keratopathy secondary to the use of ciprofloxacin after cataract surgery with confirmation by histopathological study: A case report and review of the literature

ObjectiveTo report the case of a 75-year-old patient who presented crystalline keratopathy secondary to the use of topical ciprofloxacin with histopathological verification, after cataract surgery without complications. MethodCase report with clinical and photographic follow-up, as well as slides with samples of epithelium and crystalline deposits. ResultsCorneal deposits resolved after drug suspension, topical lubricant change, and subsequent surgical debridement. The histopathological examination reported epithelial cells and basophilic particles compatible with drug precipitates. ConclusionsCrystalline keratopathy is a condition in which crystals of various kinds are deposited in the corneal epithelium and/or in the anterior stroma. It may have an infectious, pharmacological cause or, in rarer cases, corneal dystrophies. Certain factors such as a previous epithelial defect, systemic pathology with diabetes mellitus, ocular surgery and previous dry eye can favor the deposition of ciprofloxacin leading to the formation of a keratopathy.

Salzmann's Nodular Degeneration in Refractive Surgery: The Earlier Hit Hypothesis of EBM Injury-Related Fibrosis of the Subepithelial Space and Deeper Corneal Extension.

To review the atypical development of Salzmann's nodular degeneration (SND) after two cases of laser in situ keratomileusis (LASIK) and one case of photorefractive keratomileusis (PRK), and to highlight the pathophysiology of SND and its treatment. Three cases of SND (two following LASIK performed with microkeratomes and one following PRK) were reviewed and Pubmed.gov and internet searches were performed. SND is myofibroblast-generated fibrosis in the subepithelial space between the epithelium and Bowman's layer that develops years or decades after traumatic, surgical, infectious, or inflammatory injuries to the cornea in which the epithelial basement membrane is damaged in one or more locations and does not fully regenerate. It is hypothesized based on these cases, and the previous immunohistochemistry of other investigators, that myofibroblast precursors, such as fibrocytes or corneal fibroblasts, that enter the subepithelial space are driven to develop into myofibroblasts, which slowly proliferate and extend the fibrosis, by transforming growth factor-beta from epithelium and tears that passes through the defective epithelial basement membrane. These myofibroblasts and the disordered collagens, and other extracellular matrix components they produce, make up the subepithelial opacity characteristic of SND. Nodules are larger accumulations of myofibroblasts and disordered extracellular matrix. If the injury is associated with damage to the underlying Bowman's layer and stroma, as in LASIK flap generation, then the myofibroblasts and fibrosis can extend into Bowman's layer and the underlying anterior stroma. SND fibrosis often extends into Bowman's layer and the anterior stroma if there are associated Bowman's defects, such as incisions or lacerations. In the latter cases, SND frequently cannot be removed by simple scrape and peel, as typically performed for most common SND cases, but can be trimmed to remove the offending tissue. This condition is more accurately termed Salzmann's subepithelial fibrosis. [J Refract Surg. 2024;40(5):e279-e290.].

Impact of age and anterior fibromuscular stroma preservation on post-enucleation voided volume.

This study is centered on the critical role of anterior fibromuscular stroma (AFS) preservation in prostate enucleation, an emerging strategy aimed at minimizing postoperative urinary incontinence-a common concern in benign prostatic hyperplasia (BPH) surgeries. By focusing on postoperative voiding volumes (VV), our research investigates the efficacy of AFS preservation. This approach, distinct in its methodology, is hypothesized to improve urinary function post-surgery, thereby offering a potentially significant advancement in BPH surgical treatments. A retrospective analysis was conducted, comparing patients who underwent prostate enucleation in 2017 without intentional AFS preservation to those in 2019 with this technique. We examined variables including age, BMI, diabetes, hypertension, and preoperative VV to assess their effect on post-catheter removal VV. The study's methodology includes a thorough review of the primary statistical analysis methods employed. Our analysis indicates that while the 2017 and 2019 cohorts were similar in most preoperative parameters, the 2019 group that underwent AFS-preserved surgery showed a significant improvement in postoperative VVs. This was less pronounced in the patient group aged over 70, underscoring the importance of this demographic in our study. The study concludes that intentional preservation of AFS during prostate enucleation positively impacts early postoperative VVs, with limited improvement in older patients. These findings highlight the potential of AFS preservation not only in enhancing urinary outcomes post-surgery but also in shaping future BPH surgical procedures and research directions.

Central versus peripheral thickness in the human cornea explained

PurposeThe human cornea is thicker in the periphery than the center and it has been suggested that this must be due to greater numbers of lamellae in the peripheral corneal stroma. The purpose of this study was to use high-resolution ultrastructural imaging to determine if the greater thickness of the peripheral cornea is due to the presence of more lamellae or if there is some other anatomical explanation. MethodsIn this study, full thickness corneas from three human donors were processed for light microscopy (LM) and transmission electron microscopy (TEM). Images were taken in three distinct stromal regions (anterior, middle, and posterior) from the central and peripheral cornea. Stromal thickness was evaluated by LM while TEM was used to evaluate numbers and thicknesses of lamellae, mean collagen fibril diameter, and mean collagen fibril density. ResultsMean stromal thickness was significantly thinner in the central (415 ± 34 µm) compared to the peripheral (536 ± 29 µm) cornea (P = 0.009). Numbers of lamellae were not significantly different between central (246 ± 14) and peripheral (251 ± 14) cornea. Average lamellar thickness was not different across all regions of the cornea, except for the peripheral posterior where the lamellae were approximately 50 % thicker (P < 0.05). Collagen fibril diameters were larger in the peripheral cornea by approximately 30 % when compared to the central cornea, in all regions (P < 0.01). ConclusionsThis study shows that it is an increase peripheral posterior lamellar thickness, rather than an increase in the number of lamellae, that accounts for the increase in corneal stromal thickness in the periphery of the human cornea. While collagen fibril diameters are greater throughout the peripheral stroma, the lamellae in the mid and anterior peripheral stroma are not thicker than centrally.

Pearls and Pitfalls in Applying PI-RADS 2.1

AbstractThe use of Prostate Imaging Reporting and Data System (PI-RADS) with multiparametric magnetic resonance imaging (MRI) has significantly improved the detection of clinically significant prostate cancer (csPCa), but there are certain challenges that the reader may face. This review provides an overview of the pitfalls associated with the PI-RADS system for multiparametric prostate MRI (mpMRI), with suggestions/pearls to help overcome these pitfalls.PI-RADS assessment is hindered by several causes of false positives (FPs) and false negatives (FNs). In addition, there is wide variability in the positive predictive value (PPV) of the PI-RADS system across different centers, highlighting the need for improvement. While the negative predictive value (NPV) for csPCa is generally high, variations exist.This review discusses the pitfalls contributing to FNs, including MRI artifacts, such as susceptibility and motion artifacts. Techniques to optimize image acquisition, such as switching the phase encoding direction and reducing bowel peristalsis, are suggested to mitigate these artifacts. Improper b-value selection for diffusion-weighted imaging (DWI) is another pitfall, emphasizing the importance of using high b-values (≥1,400 s/mm2) to optimize neoplasm detection. Similarly, optimizing window settings to visualize csPCa, correctly positioning the endorectal coil, awareness of rare variants like mucinous adenocarcinoma and cribriform adenocarcinoma, and distinguishing central zone tumors from normal central zone are discussed.This article highlights the common pitfalls causing FPs, such as benign pathologies like prostatitis, granulomatous prostatitis, prostatic abscess, stromal BPH nodules, extruded BPH nodules, and prostatic calcifications. It also discusses the pitfalls related to normal anatomical structures, including the central zone, anterior fibromuscular stroma, thickened surgical capsule, neurovascular bundle, and periprostatic venous plexus. Techniques for carefully evaluating these entities' morphology and distribution of signal abnormalities are described to avoid overdiagnosing these as PCa. The article also addresses the pitfalls related to postintervention changes, including postbiopsy hemorrhage and artifacts caused by the UroLift procedure, while providing recommendations for managing these challenges.Finally, the pitfalls that may be encountered during staging, including evaluation for extraprostatic extension, and pelvic nodal and osseous metastases, are highlighted.

Examination of Subbasal Nerve Plexus and Central Corneal Stromal Microstructure in Subjects With Congenital Aniridia, Using in Vivo Confocal Laser Scanning Microscopy

Purpose During life up to 70% of aniridia subjects develop aniridia-associated keratopathy (AAK). AAK is characterized by limbal stem cell insufficiency, impaired corneal epithelial cell differentiation and abnormal cell adhesion, which leads to centripetal spreading vascularization, conjunctivalization, and thickening of the cornea. Our aim was to examine the subbasal nerve plexus and central corneal stromal microstructure in subjects with congenital aniridia, using in vivo confocal laser scanning microscopy CLSM. Methods 31 eyes of 18 patients (55.6% males, mean age: 25.22 ± 16.35 years) with congenital aniridia and 46 eyes of 29 healthy subjects (41.4% males, mean age 30 ± 14.82 years) were examined using the Rostock Cornea Module of Heidelberg Retina Tomograph-III. At the subbasal nerve plexus, corneal nerve fiber density (CNFD), corneal nerve fiber length (CNFL), corneal total branch density (CTBD), and corneal nerve fiber width (CNFW) were analyzed using ACCMetrics software. Keratocyte density in the anterior, middle and posterior stroma was assessed manually. Results The CNFD (2.02 ± 4.08 vs 13.99 ± 6.34/mm2), CNFL (5.78 ± 2.68 vs 10.56 ± 2.82 mm/mm2) and CTBD (15.08 ± 15.62 vs 27.44 ± 15.05/mm2) were significantly lower in congenital aniridia subjects than in controls (p < 0.001 for all). CNFW was significantly higher in aniridia subjects than in controls (0.03 ± 0.004 vs 0.02 ± 0.003 mm/mm2) (p = 0.003). Keratocyte density was significantly lower in all stromal layers of aniridia subjects than in controls (p < 0.001 for all). Stromal alterations included confluent keratocytes, keratocytes with long extensions and hyperreflective dots between keratocytes in aniridia. Conclusions Decrease in CNFD, CNFL, and CTBD, as well as increase in CNFW well refer to the congenital aniridia-associated neuropathy. The decreased keratocyte density and the stromal alterations may be related to an increased cell death in congenital aniridia, nevertheless, stromal changes in different stages of AAK have to be further analyzed in detail.

In vivo confocal microscopy findings after Descemet stripping only with and without topical ripasudil supplementation in Fuchs endothelial dystrophy

PurposeTo report corneal epithelial and corneal endothelial cell (CEC) changes following Descemet stripping only (DSO) with and without topical ripasudil using in vivo confocal microscopy (IVCM). MethodsProspective interventional case series of patients who underwent DSO for Fuchs endothelial dystrophy with or without postoperative topical ripasudil (4%, 6 times per day). Patients underwent IVCM (ConfoScan 3; NIDEK Technologies, Padova, Italy) at baseline, monthly until corneal clearance, and then every 6 months. En face images were obtained of the epithelium, anterior and posterior corneal stroma, and endothelium of the central and superior cornea. The epithelial and endothelial layer images were evaluated qualitatively. ResultsIVCM imaging was obtained from 34 patients, 26 (76%) of whom were supplemented with ripasudil and 8 (24%) of whom were not. Two eyes (6%) did not clear and required a keratoplasty. IVCM confirmed epithelial and endothelial cell morphology changes and reestablishment of a CEC mosaic. Hyperreflective nuclei, pleomorphism, multinucleated cells, and pseudoguttae were identified within the descemetorhexis. In patients on ripasudil, epithelial cells demonstrated transition from stratified squamous to spindle cell shape in regions of ripasudil-induced honeycomb edema. Migrating cells adopted an amoeboid shape and cytoplasm elongation when crossing to central stroma. Transient epithelial cell morphology changes and endothelial cell amoeboid shape changes appear to be uniquely associated with ripasudil. Rarely, figures were noted in both ripasudil-treated and non-ripasudil-treated corneas that resembled mitotic bodies. ConclusionsCECs display a range of adaptive mechanisms during healing to re-form the endothelial mosaic following DSO. Ripasudil administration appears to induce unique epithelial and endothelial cell changes.

A case of iridoschisis with partial lens dislocation in both eyes

BackgroundIridoschisis is a rare condition that primarily affects individuals aged 60–70 years. The predominant characteristics of iridoschisis involve the tissue splitting and separation of the iris stromal layers, often resulting in two distinct layers and the presence of floating fibers in the anterior chamber. This article reports the case of a 48-year-old male with iridoschisis with partial lens dislocation in both eyes.Case presentationTrauma is the leading factor in the development of iridoschisis. However, there is no documented case of ocular trauma in the patient’s medical history. Visible white atrophic fibers were observed bilaterally in the anterior iris stroma of both eyes of the individual, accompanied by a small quantity of iris tissue within the anterior chamber. In this instance, the magnitude of the iridoschisis corresponded with the degree of lens dislocation. We were apprised that the patient had regularly used a cervical massager for a prolonged period of time, positioning it upon the ocular region. Frequent stimulation of both eyes with excessive force resulted in the development of iridoschisis and the partial dislocation of the lens.During the initial surgical procedure, phacoemulsification (Phaco) was carried out on the left eye without the placement of an intraocular lens (IOL). Following a two-month interval, we proceeded with the IOL suspension. Subsequently, the right eye underwent Phaco, accompanied by the implantation of an IOL. After closely monitoring the patient’s progress for two months, it was evident that their vision had significantly improved, substantiating the success of the surgical interventions.ConclusionsThis finding posits that the recurrent friction applied to both eyes may induce iridoschisis and various ocular complications. In the event of ocular intricacies manifesting, expeditious medical intervention becomes imperative.

Changes in confocal microscopy in glaucoma patients after intraocular pressure reduction with medical therapy.

Topical glaucoma medication is the first line of management to reduce intraocular pressure (IOP) in patients with glaucoma. In this study, we intended to compare the ultrastructural findings of the cornea in patients with glaucoma before and after the reduction of the IOP through confocal microscopy. Ten patients (19 eyes) with newly diagnosed glaucoma were recruited from the glaucoma services of our tertiary care center. Demographic parameters were noted, and basic ocular examination, specular microscopy (Topcon SP3000P, Tokyo, Japan), and ultrasonic pachymetry (300 AP, Sonomed Escalon, Stoneham, MA, USA) were performed. In vivo confocal microscopy of corneal sections was performed using the z-ring Confoscan 4.0 (Nidek, Inc., Freemont, CA) at baseline and after 3 months of starting glaucoma medications. The mean age of the patients was 53.53 ± 9.34 years. There was a statistically significant reduction ( P < 0.0001) of IOP from 30.21 ± 7.42 mmHg (baseline) to 16.42 ± 4.14 mmHg (3 months). The mean central corneal thickness at baseline was 533.42 ± 3.96 µm, and it further decreased to 521.94 ± 42.45 µm at the end of 3 months ( P = 0.006). No significant change was noted in the mean epithelial cell density, mean keratocyte density in anterior and posterior stroma, and the mean endothelial cell density and cell area ( P >0.5). There was no significant percentage change in these parameters before and after the lowering of the IOP. A short-term (3 months) decrease in IOP using topical glaucoma medications caused a significant reduction in corneal thickness but did not have any significant ultrastructural changes in cornea measured using confocal microscopy.