Tarsal Conjunctiva Research Articles

Simple Epithelial Transplantation for Ocular Surface Reconstruction After Severe Ocular Burn Injury.

To manage ocular surface complications and recover conjunctival and corneal epithelia after unilateral severe chemical burn. We performed simple conjunctival epithelial transplantation (SCET) to obtain renewal of fornix and bulbar-tarsal conjunctiva epithelium, followed by simple limbal epithelial transplantation (SLET) to recover limbal function and epithelial corneal surface. Slit-lamp examination, fluorescein staining, in vivo confocal microscopy, Kheirkhah grading system for symblepharon severity, Wong-Baker FACES Pain Rating Scale, and best-corrected visual acuity were assessed before surgery, at 1 to 3 months after SCET and SLET, and thereafter at 6 to 12 to 36 months. Two patients with unilateral burn injuries underwent surgery. Eye mobility and fornix reconstruction were promptly achieved, and conjunctival epithelium with goblet cells was observed on the bulbar and tarsal conjunctiva 3 months after SCET. After SLET, corneal epithelium and cornea-conjunctiva transition zone were observed at 3 and 6 months, respectively. From before surgery to 6 months after SLET, symblepharon improved from grade IVa2 and IIIb2 to Ic0 and Ib0, the Wong-Baker FACES Pain Rating Scale changed from grade 6 and 4 to 0, and best-corrected visual acuity upgraded from 1.40 and 1.10 logarithm of the minimum angle of resolution to 0.5 logarithm of the minimum angle of resolution, in patient 1 and 2, respectively. After 3 years, results remained stable. SCET effectively healed the bare conjunctival area relieving subjective symptoms and discomfort. Sequential SCET and SLET showed to be feasible in restoring a normal ocular surface with long-lasting results suggesting the aim in patients with severe ocular burn is not merely corneal epithelium renewal but also the regeneration of ocular surface homeostasis.

An alternative instrumental method for studying the morphofunctional state of eyelids in chronic blepharitis

Background: To date, the assessment of morphofunctional changes within eyelids is performed using laser scanning confocal microscopy, which has extensive diagnostic capabilities. Identification of the indicators equivalence of this method and laser Doppler flowmetry will confirm the existence of an alternative, objective and economical method of eyelid examination in chronic blepharitis. Aim: To prove the possibility of laser Doppler flowmetry application as an alternative method of eyelid morphofunctional state assessment. Materials and methods: The study included 62 patients (124 eyes) with an established diagnosis of chronic mixed demodecticosis blepharitis, including 46 women and 16 men, mean age 65.8 ± 3.2 years, randomly assigned into two groups with identical age and gender composition. Group 1 patients (31 patients, 62 eyes) were treated with cosmeceuticals containing terpenes and terpenoids 2 times a day and tear substitute 3 times a day for 1.5 months. Group 2 patients (31 patients, 62 eyes) used an eyelid care gel containing sulphur medicaments 2 times a day and a tear substitute 3 times a day for 1.5 months. In addition to standard ophthalmological examination, laser Doppler flowmetry and laser scanning confocal microscopy were performed. Dynamic follow-up was performed after 1.5 and 3 months. Results: The analysis of laser scanning confocal microscopy and laser Doppler flowmetry parameters revealed a high inverse correlation between the density of inflammatory cells of the eyelids tarsal conjunctiva and neurogenic oscillations of blood flow, as well as high direct correlation with the index of blood flow shunting. A marked direct correlation between the density index of meibomian gland acinuses and the parameters of myogenic oscillations of blood flow and neurogenic oscillations of lymph flow was established. Conclusions: Pearson’s correlation analysis performed on laser scanning confocal microscopy and laser Doppler flowmetry parameters assessing the morphofunctional state of the eyelids demonstrated the presence of equivalence in both study groups with high statistical reliability. The obtained data confirm the possibility of using laser Doppler flowmetry method for objective assessment of eyelid condition and allow the parameters of this method to serve as criteria for choosing pathogenetically oriented therapy of chronic blepharitis with evaluation of its effectiveness.

Acquired Ankyloblepharon Correction Using Ocular Surface and Tarsal Mucous Membrane Grafting in Cicatrizing Ocular Surface Diseases

Purpose: To report the long-term surgical outcomes of acquired ankyloblepharon correction using mucous membrane graft. Methods: Five eyes of 4 patients (median age, 19 years) with acquired ankyloblepharon were managed using eyelid splitting and mucous membrane graft anchored to the recti muscles on the bulbar surface in the respective quadrant and onto the bare tarsal surface. Outcome measures include a change in the palpebral fissure width, ability to fit scleral contact lenses, visual acuity, and cosmesis. Results: The underlying etiologies of ankyloblepharon were chronic Stevens-Johnson syndrome (n = 3), and chemical injury (n = 2). All 5 eyes had conjunctival shortening, and 3 had severe dry eyes (median Schirmer 4.5 mm). Four eyes had limbal stem cell deficiency. The median horizontal palpebral fissure width improved to 22 mm from 8 mm. This single-staged surgical technique allowed for fornix formation and prosthetic replacement of the ocular surface ecosystem lens fitting in all 5 eyes. Median logMAR visual acuity improved from 2.1 to 0.7 following ankyloblepharon release, prosthetic replacement of the ocular surface ecosystem lens fitting in 4 eyes, and keratoprosthesis in 1 eye. Repeat mucous membrane graft for recurrent symblepharon in 1 quadrant was required in 2 eyes where complete 360 degrees bulbar and tarsal conjunctiva loss were present preoperatively. At the median follow-up period of 27 months, all patients reported better cosmesis and had no symblepharon recurrence following repeat surgery in 2 eyes and single surgery in 3 eyes. The donor site healed well without any complications. No mitomycin C or symblepharon ring was used. Conclusion: Ocular surface and adnexal reconstruction using bulbar and tarsal mucous membrane grafts help visually rehabilitate patients with acquired ankyloblepharon secondary to cicatrizing ocular surface disorders.

Correlation of Clinical Severity of Trachomatous Inflammation and Chlamydia trachomatis Bacterial Load.

The purpose of this study was to investigate the correlation between bacterial load of Chlamydia trachomatis as measured from quantitative polymerase chain reaction (qPCR) and the relative clinical severity of trachomatous inflammation. Individuals with trachoma from rural communities in Ethiopia had photographs taken as well as swabs obtained of the upper tarsal conjunctivas. Conjunctival swabs were processed with PCR assay, which provided quantitative results of ocular chlamydial load. A series of 125 conjunctival photographs were ranked from least to most severe according to clinical severity for follicular and papillary conjunctivitis. Higher intensity rankings of trachomatous inflammation were associated with higher chlamydial load for both follicular inflammation (Spearman's ρ = 0.43; P <0.001) and papillary inflammation (Spearman's ρ = 0.50; P <0.001). Rankings of trachomatous inflammation may be a clinically meaningful indicator of trachoma.

Ocular surface complications secondary to eyelid resection of infiltrating basal cell carcinoma

A 77-year-old female patient with the presence of a cutaneous neoformation of approximately 1 cm by 1 cm was verified at the level of the middle third and external third of the right lower palpebral eyelid, which extended to the tarsal conjunctiva of the fornix. It was decided to perform closed dacryointubation with silicone tube placement, full thickness resection of the lesion with free edges, cheek and preauricular skin rotation flap (Mustardé type) associated with autologous chondro-perichondral graft of the external ear (Matsuo type), with oral mucosa graft to restore the posterior lamella. After 15 days, the patient reports a foreign body sensation at the level of the right eye. irregularity and malposition of the lower eyelid edge, positioning abnormality of the cutaneous mucosal junction line, conjunctival hyperemia, tear breakup time of 5 seconds, tear meniscus measurement of 0.3 mm and 0.5 mm, inferior punctate epithelial keratopathy, which stains with fluorescein.

Severity of Trachomatous Scarring among Adults in Trachoma-Endemic Amhara Region of Ethiopia.

Trachomatous scarring has been shown to progress regardless of active ocular Chlamydia trachomatis infection, indicating that scarring drivers may be unrelated to ongoing transmission. Although scarring prevalence is commonly associated with older age and female sex, less is known about other potential contributors to its development. This study identified and assessed risk factors associated with scarring magnitude in a trachoma-endemic setting, utilizing a five-point photographic scale (S0-S4). During 2017 trachoma surveys of Amhara, Ethiopia, photographers captured left and right conjunctival images of adults (ages 15 years and older) from 10 districts. Subsequently, two graders independently assessed photographs for scarring, with discrepancies adjudicated by an expert grader. Scarring scores for 729 individuals were aggregated from the eye level to the participant level, excluding 17 participants because of poor photograph quality. Among those with scarring, most cases (20.4%) were severe (S4, comprising more than 90% of the tarsal conjunctiva) compared with the prevalence of moderate S3-A/B (11.2%), S2 (8.3%), and mild S1 (19.2%). The youngest group (ages 15-19 years) exhibited all scarring stages. Older participants (60 years and older) experienced a greater burden of severe scarring (S4 prevalence: 32.6%) than their younger (15-19 years) counterparts (6.2%). Multivariate ordinal logistic regression models indicated female sex, increasing age, and district-level trachomatous follicular-inflammation prevalence were significant predictors of scarring severity. Trachomatous scarring and its progression to trichiasis, may prove a barrier to meeting WHO timelines for trachoma elimination and will necessitate ongoing surveillance and interventions after elimination thresholds have been met.

Scleral lens surface crazing in an eye with giant papillary conjunctivitis and keratoconus: Outcome of lens surface polishing

We present a case of scleral lens surface crazing in a patient with keratoconus (KC) and chronic giant papillary conjunctivitis (GPC). A 45-year-old Asian male with known keratoconus (KC) and allergic eye disease in both eyes, who is an experienced scleral lens user, presented with a 3-month history of lens intolerance in the right eye. On examination, the right eye scleral lens showed extensive lens surface crazing with poor surface wettability. The upper tarsal conjunctiva showed conjunctival hypertrophy – active GPC. After allergy treatment and symptomatic improvement, the scleral lens was refitted after intensive cleaning and polishing with aluminum oxide. The lens surface showed significant improvement and good fitting characteristics, and the patient resumed lens wear. At 6 months of follow-up, the patient was asymptomatic, and the ocular condition was stable.

Assessment of Conjunctival Surface Changes in Post COVID Patients by Impression Cytology

Abstract Background The conjunctiva is a transparent, clear, thin membrane that covers part of the eye’s front surface and the inner surface of the eyelids. It is divided into three regions: the palpebral or tarsal conjunctiva, the bulbar or ocular conjunctiva, and the conjunctival fornices. The novel coronavirus (COVID-19), named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was first identified in December 2019 after a series of acute atypical lung disease cases occurred in Wuhan, China. Aim of the Work The aim of the our study is assessment of the inflammatory and neoplastic changes that happened on the ocular surface especially the conjunctiva according to Nelson staging system in post-COVID-19 patients and evaluated by impression cytology. Patients and Methods This study was conducted on a selected sample of patients attending the Ophthalmology outpatient clinic of Ain Shams University Hospitals in Cairo, specimens of impression cytology were stained and examined in the Pathology department of Ain Shams University. Results In the present study, comparison between cases and controls groups as regards epithelial cells showed that in cases group there was normal, small, round cells in 19(59.4%) cases, slightly larger, more polygonal cell in 11(34.4%), and Larger, polygonal cells in 2(6.3%), and in controls group, there was normal, small, round cells in 25(78.1%) cases, slightly larger, more polygonal cell in 7(21.9%), there was no statistically significant difference between the two groups as regards epithelial cells (p &amp;gt; 0.05). Furthermore, As regards N/C ratio where in cases group the ratio was 1:2 in 19(59.4%) cases, 1:3 in 11(34.4%), and 1:4-1:5 in 2(6.3%), and in controls group, it was 1:2 in 25(78.1%) cases, 1:3 in 7(21.9%), there was no statistically significant difference between the two groups as regards N/C ratio. In the current study, as regards Keratinization where 6(18.8%) cases had mild keratinization in cases group in comparison to 2(6.3%) cases in controls group. There was no statistically significant difference between the two groups as regards Keratinization (p &amp;gt; 0.05). Moreover, we found that there was no dysplasia in both cases and controls groups. The comparison between cases and controls groups as regard Goblet cells where in cases group the goblet cells was stage 0 in 17(53.1%) cases, others was stage 1 in 13(40.6%), and the cells was stage 2 in 2(6.3%), and in controls group, there was stage 0 cells in 22(68.8%) cases, stage 1 in 10(31.3%), there was no statistically significant difference between the two groups as regard goblet cells density. Conclusion There is non significant inflammatory or neoplastic changes that have been occurred in conjunctival surface in post-COVID-19 patients. Except for lymphocytes infiltration.

Clinical pattern of vernal keratoconjunctivitis in children – A cross-sectional study

Background: Vernal keratoconjunctivitis (VKC), a chronic and bilateral allergic eye condition, predominantly affects young males and is more prevalent in hot, humid regions with high allergen exposure. It manifests with itching, light sensitivity, burning sensations, and tearing. The three main clinical forms include limbal or bulbar, palpebral or tarsal, and mixed presentations. Aims and Objectives: This study aimed to describe the clinical patterns of VKC in children at a tertiary care hospital in Andhra Pradesh. Materials and Methods: This cross-sectional observational study was conducted in a hospital setting at the Department of Ophthalmology, SV Medical College in Tirupati, Andhra Pradesh, between January 2021 and January 2022. Ninety children aged 5–12 years with symptoms of allergic conjunctivitis were enrolled in the study. The Bonini grading system was used to grade the severity of the disease based on clinical manifestations at the time of initial presentation. Results: Mean age of disease onset was 8.6±2.3 years, with a male-to-female ratio (M: F) of 2.1:1. The majority of the subjects experienced seasonal occurrence 69 (77.0%), whereas 21 (23%) had perennial occurrence. The commonly reported symptoms included itching (83%), redness (73%), watering (73%), and discharge (47%). A significant number of patients (60, 69%) had a mixed type of disease that affected both the tarsal and bulbar conjunctiva. Conclusion: VKC predominantly affects young males, displaying a seasonal distribution and showing less allergic association, consistent with patterns observed in other tropical regions. Most patients had mild VKC at presentation, and a mixed-form pattern was most frequently observed.

Delayed diagnosis of ocular graft-versus-host disease after allogeneic hematopoietic stem cell transplantation

PurposeTo investigate the delayed diagnosis of chronic ocular graft-versus-host disease (coGVHD) after allogeneic hematopoietic stem cell transplantation (alloHCT), and further analyze potential confounding factors. MethodsThis cross-sectional study included 118 patients newly diagnosed as coGVHD after alloHCT at Zhongshan Ophthalmic Center, Sun Yat-sen University. All participants finished the flow path of medical history taking, detailed ophthalmological examination and questionnaire-based survey. coGVHD was diagnosed and graded by International Chronic Ocular GVHD Consensus Group (ICOGCG) criteria. Lag time of diagnosis was defined as interval between noting of ocular symptoms and confirmed diagnosis of coGVHD (TN-D). We further compared the clinical parameters between groups categorized by the median TN-D as medium and long delay groups. ResultsThe median TN-D was 6.3 [IQR 2.8–14.5] months. Most coGVHD patients underwent delayed diagnosis of coGVHD longer than 3 months (70 %, 83 of 118), with 90 of 118 diagnosed as severe coGVHD (76 %). The long delay group exhibited higher ICOGCG scores (10 [IQR 9–10.5] vs. 9 [IQR 8–10], P = 0.039) and more pronounced ocular signs, including conjunctival injection, meibomian gland loss, fibrotic tarsal conjunctiva, symblepharon, and corneal complications (all P < 0.05). Delayed diagnosis was strikingly correlated with seeking ophthalmic medical care twice or more prior to diagnosis (adjusted OR = 5.42, 95%CI: 1.40–21.06, P = 0.015) and accurate knowledge of ocular discomfort symptoms in coGVHD (adjusted OR = 0.29, 95%CI: 0.08–1.00, P = 0.050). ConclusionsDelayed diagnosis of coGVHD, associated with disease severity, was common among alloHCT recipients in southern China. Improving patient education and the awareness of ophthalmologists may facilitate early diagnosis of coGVHD.

Congenital eyelid imbrication syndrome: a rare occurrence in Pakistan

Congenital eyelid imbrication syndrome (CEIS) is a rare condition presenting at birth and is characterised by overriding of the upper lid on the lower lid. It is due to longer upper lid, than the lower lid. Overriding leads to spontaneous eversion of the upper lids. In our patient, examination revealed canthal tendon laxity and hyperaemia of the tarsal conjunctiva. All the rest of the structures in the eyeball and adnexa were normal. Spontaneous eversion occurred in two weeks as the upper lid grew with time. No treatment was required. Keywords: Congenital imbrication syndrome, Overriding upper lid, Hyperaemic conjunctiva, Floppy eyelids.

Shave Excision Of Marginal Lower Eyelid Nevus

Introduction : INTRODUCTION: Nevus is a common benign melanocytic lesion and may appear in palpebral region. It may appear congenitally or acquired. Such lesions contain melanocyte derived from neural crest. Palpebral nevus is a group of heterogenous lesion with varying clinical and histological presentation depending on age and nevus stage. PURPOSE: To report shave excision procedure of the left inferior palpebral nevus located in the palpebral margin using local anesthesia.&#x0D; Case Illustration : CASE REPORT: A 43-years old woman came to the hospital with a solitary mass in the lower right eyelid. The mass was experienced since 2 year ago and slowly increasing in size and most notably 3 months prior. The mass was round, tender, painless, black-greyish colored, with a smooth surface, mobile, and measured 0,5 cm x 0,5 cm in size. The lesion was located in the middle portion of right lower palpebral margin without extension to the tarsal or bulbar conjunctiva. No bleeding or discharge was found. No history of trauma, use of medication, family history, previous ocular and systemic disease was found. Histopathological examination concluded the lesion was nevus pigmentosus. The nevus was excised entirely using shave excision technique with local anesthesia. Follow-up examination revealed an excellent result with no complications.&#x0D; Discussion : &#x0D; Conclusion : CONCLUSION: Palpebral nevus pigmentosus are common benign tumor with wide range of clinical and histological manifestation. Not all palpebral nevus required surgical intervention. The most effective treatment is complete excision of the nevus and recurrence rate is generally low.

SIE BOEN LIAN (SBL) SURGICAL TECHNIQUE FOR CICATRICIAL ENTROPION AFTER STEVENS-JOHNSON SYNDROME

Introduction : Stevens-Johnson Syndrome (SJS) can cause keratinization of the tarsal conjunctiva, conjunctival scarring and inverted eyelid margin, resulting to cicatricial entropion, causing skin and lashes to brush against the eye. This condition can occur in 27-59% of cases in ocular SJS. The surgical treatment for cicatricial entropion is to repair the position of eyelid margin. One of the procedures that can be used is Sie Boen Lian (SBL) technique.&#x0D; Case Illustration : A 70-year-old woman complained of inversion of the left upper eyelid, which caused foreign body sensation, redness, and lacrimation since 4 months ago. The patient had a history of SJS caused by the use of quinolone antibiotic. Anterior segment examination revealed entropion in the left upper eyelid with palpebral margin keratinizing. The patient was diagnosed with cicatricial entropion post- SJS. SBL surgical technique was chose to manage this condition. Post-operative ophthalmological examination showed a relieved symptoms and an improvement in the position of the eyelid margin.&#x0D; Discussion : The primary goal of therapy in cicatricial entropion is to reduce the occurrence of chronic ocular irritation by reverting the structure of the eyelids to a physiological position. The anterior lamellar shortening was performed with a modified tarsotomy, known as the SBL surgical technique. The post-operative evaluation was implemented to assess the reposition of the eyelid margin.&#x0D; Conclusion : The SBL surgical procedure is effective to manage cicatricial entropion post-Steven-Johnson Syndrome.

CICATRICIAL ECTROPION REPAIR DUE TO TRAUMA : A CASE REPORT

Introduction : Cicatricial ectropion is a complication that can occur after trauma. Scar tissue formation causes anterior lamellae shortening (skin and orbicularis muscle), resulting in outward lid margins rotation.&#x0D; Case Illustration : A 16 y.o male patient came with complaints of the left upper and lower eyelids folding outwards since 3 months ago after trauma, watery eye. Examination VOD 20/20, VOS 20/50. Scar on the superior and inferior lids, the inferior lid margin is folded out, inferior tarsal conjunctiva is visible, lagophthalmus 4 mm, fissure palpebral vertical (FPV) 12 mm, margin reflex distance (MRD) 1 = 4 mm, MRD2 = 8 mm, fissure palpebral horizontal (FPH) 30 mm, conjunctival injection. Corneal (macular) scars central-peripherally at 3-6 o'clock. Patient was diagnosed with cicatrical ectropion with left eye corneal scar and ectropion repair was performed with full-thickness skin graft from retroarticular. One week and six weeks after surgery, FPV improved to 10 mm, MRD1 = 4, MRD2 = 6 mm, FPH 30 mm, and lagophthalmos 2 mm became 1 mm.&#x0D; Discussion : Cicatricial ectropion is usually treated in 3 procedures: release vertical scar traction, horizontal lid tightening, repair anterior lamella can be done with full-thickness skin graft. horizontal lid tightening in this case not carried out because of no laxity.&#x0D; Conclusion : Scar traction release and repair anterior lamella with full-thickness skin graft from retroauricular was choice in this case because extensive defect and ectropion grade 3. After surgery anatomical structure of the lids and looks better aesthetically.

A Case: The Strategy of Corneal Ulcers

Introduction : Corneal ulcers are considered an ophthalmologic emergency because of their potential to permanently impair vision or perforate the eye. Accurate and quick diagnosis and prompt treatmentis a key to improve clinical and visual outcomes in cases of corneal ulceration.&#x0D; Case Illustration : In this paper, we present the case of male 40-year-old presented with complaints of pain and defective vision in the right eye. Visual examination of the right eye is 1/~. It was found, palpebral edema, hyperemic tarsal conjunctiva. The bulbar conjunctiva showed conjunctival injection, ciliary injection. The cornea looks completely cloudy, the surface is not slippery, infiltrates and edema. The patient was treated with medical and surgical therapy, and then the patient’s have a good clinical response and was able to return to work.&#x0D; Discussion : The diagnosis of corneal ulcers was established based on history, physical examination and clinical examination using a slit lamp and laboratory examinations. Patient's examination revealed the presence of Candida albicans. This examination is important to distinguish the cause of the corneal ulcer so that it can help select an adequate therapy.&#x0D; Conclusion : Indonesian farmers have highrisk of fungal corneal ulcers. Fungal corneal ulcers is important cause of corneal blindness all over the world especially in develoving countries. Fungal corneal ulcers can diagnosis by slitlamp biomicroscopic examination and culture are essential for early specific diagnosis and must be taken consideratiaon to establish the most effective treatment and avoid severe complications

COMBINED PAPILLECTOMY AND AUTOLOGOUS CONJUNCTIVAL MEMBRANE GRAFT AS MANAGEMENT FOR SEVERE, REFRACTORY PALPEBRAL VERNAL KERATOCONJUNCTIVITIS: A CASE REPORT

Introduction : Vernal keratoconjunctivitis (VKC) is a type of allergic conjunctivitis which often occurs repeatedly and chronically. It is unusual compared to other types of conjunctivitis due to its giant papillae (GP) manifestation that may cause serious complication on cornea and eventually lead to permanent vision loss. We present a surgical treatment—resection of GP—in conjunction with autologous conjunctival membrane graft to manage a severe case of VKC.&#x0D; Case Illustration : An 18-year-old male came with a prior history of recurrent acute allergic keratoconjunctivitis since seven years before. His GP had caused shield-like ulcer, which leads to corneal scar and interferes with his visual acuity. He also had mechanical ptosis due to the giant cobblestones. His symptoms were then managed by performing combined papillectomy and autologous conjunctival membrane graft.&#x0D; Discussion : During surgery, the GP on both of his eyes were excised until tarsus was visible. Autologous conjunctival membrane was grafted from superior quadrant of each eye, and sutured tightly onto the excised tarsus. Six month postoperatively, his superior tarsal conjunctiva remain relatively smooth, with well-controlled symptoms of keratoconjunctivitis.&#x0D; Conclusion : Combined papillectomy and autologous conjunctival membrane graft can be considered as an adjunctive intervention to medications, in patients with severe, refractory cases of palpebral vernal conjunctivitis. It can alleviate symptoms and reduce the possibility of permanent damage on corneal tissue.

Corneo‐conjunctival sensory neuron: Types, transduction channels and codification of nerve impulses

The cornea and the conjunctiva are innervated by the peripheral projections of a small number of primary sensory neurons whose somata are located at the ophthalmic region of the trigeminal ganglion. Most trigeminal neurons innervating the ocular surface are small and medium size, and contain neuropeptides such as SP and CGRP. Functionally, ocular surface neurons have been classified into five main neuronal types, based on their response to multiple modalities of stimuli (mechanical forces, heat, cold, H+, chemical substances, etc.). Polymodal nociceptors (activated by several modalities of stimulus, mechanical energy, heat, H+, and chemical irritants), mechanonociceptors (activated by mechanical energy), cold thermoreceptors (activated by temperature reductions and hyperosmolarity) are found in the cornea, the sclera and the conjunctiva. Besides, low‐threshold mechanoreceptors (activated by mechanical forces of low intensity) are found in the corneoscleral limbus and the lid border, and pruriceptors (activated by pruritogen substances) have been described in the tarsal conjunctiva, close to the lid margin.The ability to respond to the different modalities of stimulus lies in the types of transducing channels that each type of neuron expresses at its peripheral nerve endings. Sensory transduction involves the conversion of the physical or chemical stimuli acting on the nerve terminal into electrical energy, that is, into a local change of membrane potential that, if it is large enough, will generate action potentials that will travel along the axon to be processed by the CNS. So that, nerve terminals with TRPV1 channels are directly gated by heat, H+, and several chemical irritants such as capsaicin; nerve terminals with Piezo2 channels will be activated by mechanical forces; TRPM8 channels provide nerve terminals sensitivity to cold and osmolarity increases; et cetera.Ocular sensory neurons also express other ion channels that contribute to coding, that is to help the sensory neuron to establish a correspondence between the characteristics of the stimulus (intensity, temporal course, etc.) and specific parameters of the firing it induces. Voltage‐gated Ca2+, Na+ and K+ channels as well as cyclic nucleotide‐gated channels, among others, contribute to define the firing frequency and pattern to encode the traits of the stimulus. Thus, the ion channels present in the nerve terminals of each class of ocular sensory neuron provide the neurons the ability to detect and encode one or several modalities of stimulus, which constitutes the origin of the different sensations evoked on the ocular surface.(Supported by PID2020‐115934RB‐I00 from DOI: MCIN/AEI/10.13039/50110001103, and CIPROM/2021/48 from the Generalitat Valenciana, Spain)

Correlative microscopy (CLEM) of tarsal conjunctival scraping: A new opportunity in the diagnosis of microbial keratitis

Aims/Purpose: To evaluate the efficacy of correlated Scanning Electron Microscopy (SEM)/Optical Microscopy (OM) analysis of conjunctival scrapings in diagnosing infectious keratitis with prior negative culture tests or ineffective broad‐spectrum antibiotic therapy.Methods: 102 eyes of 87 patients (45M, 42F) affected by keratitis were evaluated by cytological examination of scrapings of the superior tarsal conjunctiva in OM (Nikon Eclipse 50i) and SEM (JEOL), after 72 h of wash‐out. Inclusion criteria: age &gt; 18 years, corneal epithelial defects from suspected infection, ineffectiveness of previous broad‐spectrum antimicrobial therapy or negative conjunctival swab. Exclusion criteria: ocular surgery &lt;3 months, immunosuppression, allergic keratitis, severe dry eye, ocular herpes, ulcer &gt;3 mm, anterior chamber involvement. Identification of inflammatory infiltrate (OM) and microorganisms (SEM) was performed by two independent operators with the same devices and methodology. Weekly clinical control with new conjunctival scraping for OM and SEM after cycles of therapy were carried out.Results: Pathogenic microorganisms were detected in 94/102 eyes: Acanthamoeba (22), Candida (18), Mycoplasma (15), Mycobacteria (13), Chlamydia (12), Micrococci (11), Pseudomonas (6), Cocci (6), Aspergillus (5), Fusarium (2); in 14 cases 2 or more different forms coexisted; in 2 cases a subsequent PCR test revealed the presence of HSV‐1; 3 cases showed signs of severe dry eye; other 3 marked eosinophilia. Operator agreement: 99%. The specific treatment for the germs detected determined in all cases clinical and microbiological resolution in 14–49 days (mean 27.6 ± 2.4).Conclusions: CLEM put in evidence the correlation between phlogistic cells and pathogens, allowing the diagnosis and the treatment of different forms of infectious keratitis and other pathological conditions. The interpretation and repeatability, however, require appropriate training and dedicated equipment.

Multimodal treatment for extensive recurrent lentigo maligna melanoma

Lentigo maligna melanoma (LMM) is a type of invasive melanoma. When LMM comprises periocular and ocular tissues, sequential multimodality treatments may be needed to avoid wide surgical excisions. We report the case of a recurrent LMM after multiple excisions elsewhere that involved the entire lower eyelid and lateral part of the upper eyelid skin, extending to the lower tarsal conjunctiva and conjunctival fornix. It was successfully controlled by a multistep approach using orthovoltage radiotherapy, topical chemotherapy, and cryotherapy, saving the patient from exenteration. The patient is still in disease-free status in the fourth year after multistep approach.

Contact lens‐related complications

The use of contact lens is very popular and its global market is growing. They have numerous applications, some well‐established and others still not consensual but which have been gaining more and more approval, namely refractive errors, dry eye management, post refractive surgery rehabilitation, persistent epithelial defects, cosmetic approaches and drug delivery systems. Unfortunately, there are some complications caused by their use, some of them sight threatening. The purpose of this presentation is to review these problems and to provide a better understanding of them.The major mechanisms implicated are numerous: trauma, decreased corneal oxygenation, reduced corneal and conjunctival lubrication, allergic and inflammatory responses and infection. However, depending on the complication we are talking about, there are other factors involved, such as contact lens‐related factors (material, design, fit and wearing schedule) and environmental factors (ocular surface condition, external environment, occupational factors, medications and compliance).The symptomatology experienced by patients ranges from hypoesthesia and mild conjunctival hyperemia to photophobia, contact lens intolerance and even decreased visual acuity.Many complications have been described. The most important (most common or most serious) are contact lens discomfort (CLD), dry eye, corneal deepithelialization (CD), sterile infiltrates (SI), corneal neovascularization (CNV), infectious keratitis (IK) and giant papillary conjunctivitis (GPC). Superior epithelial arcuate lesion, contact lens‐related peripheral ulcer, corneal distortion, hypoesthesia, ptosis, pinguecula, corneal edema, allergy aggravation, herpes reactivation and endothelial changes have also been described.CLD is an episodic or persistent adverse ocular sensation related to lens wear with a variable incidence in the literature, ranging from 23% to 94% in different series, being less common with soft lenses. Dry eye plays its role acting as a risk factor for CLD and/or as a consequence of contact lens use. CD manifests as punctate epithelial keratopathy, epithelial abrasions, foreign body tracks, corneal dellen, microcysts, vacuoles, mucin balls and dimple veiling. GPC is one of the most common adverse effects of contact lenses and the papillary reaction of the upper tarsal conjunctiva is the main feature of this entity. CNV is the formation of new vessels basically found in capillaries and venules of the pericorneal plexus, which may progress to the corneal stroma. They are much more associated with soft contact lenses, especially in extended wearers. Of note, contact lens use is one of the most common causes of CNV usually highlighted. SI are the result of an immunological reaction, often do not contain overlying epithelial defect or anterior chamber reaction and may manifest as stromal deep opacities. IK may be caused by bacteria, viruses, fungus or parasites and prompt immediate care and close revaluations to anticipate disastrous outcomes.Conservative measures play a role in almost all complications and their prevention, such as patient education, lubrication, contact lens exchange when applicable and modification of environmental factors. Addressing and learning how to prevent or quickly diagnose all these complications is crucial to prevent serious consequences.