Cornea : The Journal of Cornea and External Diseases

ICYMI: Cornea Update: Assessment of Corneal Crosslinking for the Treatment of Corneal Neovascularization With and Without Associated Infection: Purpose: To evaluate investigational use of corneal crosslinking (CXL) to treat corneal neovascularization (CNV) with or without concomitant infection. Methods: This prospective, single-center study assessed investigational use of epithelium-off CXL with 0.1% riboflavin/20% dextran ophthalmic solution to treat various scenarios of CNV with standard 30-minute or accelerated 10-minute irradiation. Results: The CXL treatment was investigated for 38 CNV scenarios in 37 eyes of 35 participants (2 bilateral) and was repeated once in 2 eyes and twice in 1 eye. Treatment was considered successful in 24 cases, partially successful in 1 case, and unsuccessful in 8 cases; 2 cases were lost to follow up and 3 developed complications unrelated to the CXL that precluded efficacy evaluation. The CXL was considered successful in all 4 cases treated for CNV with melting and/or cheese wiring of the recipient cornea postkeratoplasty, in 7 of 9 cases with active infection, in 5 of 10 cases treated in conjunction with penetrating keratoplasty, in 3 of 4 cases treated in conjunction with lamellar keratoplasty or wound revision, and in 6 of 11 cases without associated infection or surgery. Conclusions: Investigational use of CXL can contribute to CNV regression in the following scenarios: postkeratoplasty corneal melting and suture cheese wiring, infectious keratitis, and combined with keratoplasty. However, it has limited, if any, benefit in treating CNV in situations where the stimulus for CNV is not eliminated, such as ongoing infection or chronic conditions such as limbal stem cell dysfunction. http://dlvr.it/TJzttn #Cornea #Ophthalmology #Ophthotwitter

ICYMI: Cornea Update: Cyanoacrylate Glue Patch for Corneal Melting in Keratoprosthesis: Purpose: To report clinical outcomes of cyanoacrylate glue patches in managing corneal melting in keratoprosthesis (KPro). Methods: Multicenter, retrospective, noncontrolled, interventional case series. Subjects underwent cyanoacrylate glue patches for corneal melt after KPro implantation, regardless of the underlying cause, KPro design, or melt severity. Clinical success was defined as resolving aqueous leak, halting further corneal melting, and avoiding KPro or carrier corneal graft exchange for at least 12 months after cyanoacrylate glue patch application. Results: Sixteen eyes of 15 patients with KPro underwent a cyanoacrylate glue patch for corneal melting. The mean time from KPro implantation to the development of corneal melt was 49.2 months. Implanted KPro models included Lucia (37.5%) and Boston type 1 with titanium (31.2%) or polymethylacrylate backplate (31.2%). Underlying etiologies for KPro implantation included recurrent graft rejection (56.2%), autoimmune disease (31.2%), and chemical injury (12.5%). A combined procedure with a cyanoacrylate glue patch and amniotic membrane transplantation was performed in 2 cases. The criteria for clinical success were met in 87.5% of patients, with only 2 eyes (12.5%) exhibiting clinical failure. Glue patches were retained successfully for a mean time of 25.50 ± 23.87 months (range: 0–84 months). Conclusions: Cyanoacrylate glue patches provide a simple, safe, cost-effective, and effective treatment for corneal melts in patients with KPro. http://dlvr.it/TJzttl #Cornea #Ophthalmology #Ophthotwitter

ICYMI: Cornea Update: Epidemiology of Corneal Ulcers Diagnosed in the Emergency Department in California: Purpose: To determine the incidence, seasonality, geographic distribution, and risk factors for emergency department presentations with corneal ulcers and perforated corneal ulcers. Methods: Retrospective, population-based cohort study of corneal ulcers in California from 2012 to 2021. Overall and stratified yearly incidence rates, seasonality, individual-level and postal code-level risk factors for perforation, and geographic clustering were evaluated. Results: This study included 31,019 emergency department (ED) visits for corneal ulcers, with 263 cases coded as perforated corneal ulcers. The average yearly incidence was 7.94 (95% confidence interval, 7.85–8.03) per 100,000 people for ED-diagnosed corneal ulcers and 0.67 (95% confidence interval, 0.59–0.76) per 1,000,000 people for perforated corneal ulcers. Male patients, Black patients, and primary English-speaking patients had the highest incidences across sociodemographic groups. For ED-diagnosed corneal ulcers, the incidence was highest among individuals aged 20 to 60 and for perforated corneal ulcers the incidence was highest among individuals over age 75. Significant geographic clustering was observed, with hotspots in the Central Valley and inland Northern and Southern California. Visits were seasonal, with incidence peaking in July and lowest in February. Increasing age, Spanish as a preferred language, and having health insurance were significant risk factors for presenting with a perforated corneal ulcer. Indicators of low socioeconomic status were associated with higher rates of corneal ulcers. Conclusions: The incidence of ED-diagnosed corneal ulcers in California increased over the study period with a notable seasonal pattern. Higher rates were observed in Black individuals and in areas with lower socioeconomic status, providing evidence of health disparities and identifying potential targets for public health interventions. http://dlvr.it/TJzttj #Cornea #Ophthalmology #Ophthotwitter

ICYMI: Cornea Update: Anterior Segment Swept-source Optical Coherence Tomography in Ocular Surface Tumors and Simulating Lesions and Correlation With Histopathologic Diagnosis: Purpose: To investigate anterior segment swept-source optical coherence tomography (AS SS-OCT) findings in ocular surface tumors and simulating conditions. Methods: AS SS-OCT imaging and histopathologic data pertaining to 92 eyes of 86 cases collected between September 2018 and April 2023 were evaluated. Results: The 3 most common lesions were conjunctival nevus (18 eyes), ocular surface squamous neoplasia (OSSN, 16 eyes), and pterygium/pinguecula (13 eyes). Excisional/incisional biopsy was performed in 58 of 86 (67.4%) cases. On AS SS-OCT, conjunctival nevi demonstrated mildly hyperreflective epithelium of normal thickness, internal hyperreflectivity, and intralesional cysts. OSSN showed epithelial hyperreflectivity, epithelial thickening, and an abrupt transition between normal and abnormal epithelium. Differences between median maximal epithelial thickness on AS SS-OCT for OSSN and pterygium (560 vs. 102 μm), OSSN and pseudopterygium (560 vs. 113 μm), OSSN and pinguecula (560 vs. 72.5 μm), and OSSN and conjunctival papilloma (560 vs. 965.5 μm) were statistically significant (P < 0.001, P < 0.001, P < 0.001, and P = 0.039, respectively). By receiver-operating characteristic curve, using 630.5 μm as a cutoff, the sensitivity and specificity of AS SS-OCT for differentiating between conjunctival papilloma and OSSN were 69% and 100%, respectively (P = 0.038). The presence of hyporeflective spaces/cysts was statistically significant in conjunctival papilloma compared to OSSN (P < 0.001) and in conjunctival nevus compared to conjunctival melanoma (P = 0.002). Conclusions: AS SS-OCT is a useful tool in differentiating OSSN from pterygium/papilloma and conjunctival nevus from melanoma. It provides important in vitro information on many other lesions including conjunctival lymphoma, primary acquired melanosis, and conjunctival amyloidosis. http://dlvr.it/TJzttg #Cornea #Ophthalmology #Ophthotwitter

ICYMI: Cornea Update: Central Cornea Changes on Anterior Segment OCT and In Vivo Confocal Microscopy After Autologous Limbal Epithelial Cell Transplantation: Purpose: To describe 1-year changes in the cornea as assessed by anterior segment optical coherence tomography (AS-OCT) and in vivo confocal microscopy (IVCM) for participants receiving a tissue graft generated from a new manufacturing process using cultivated autologous limbal epithelial cells. Methods: Cultivated autologous limbal epithelial cell grafts were produced in a 2-stage manufacturing process following a good manufacturing process-compliant protocol. AS-OCT and IVCM were completed at baseline and 12 months after the treatment in subsets of these participants. Secondary efficacy outcomes were determined based on improvement of central corneal epithelial morphology and thickness [corneal epithelial thickness (CET)] and presence of conjunctival or corneal cells in central cornea. Results: Among 14 participants, 13 (93%) were male, 12 (86%) were white, the mean age was 46 ± 16 years. At baseline, CET was 53 (range: 34, 64) microns, and epithelial basal cell density was 3964 (range: 822–5788) cells/mm2; the ratio of the cells at central cornea was 20% corneal and 90% conjunctival epithelial cells. At 12 months, the mean changes were 3 μm in CET (P = 0.67), and 1967 cells/mm2 in epithelial basal cell density (P = 0.02); the proportion of the central cells improved to 75% corneal and 38% conjunctival epithelial cells. Conclusions: The AS-OCT and IVCM findings are consistent with the clinical improvement, indicating the reconstitution of the corneal phenotype and clearing of the optical axis. Nevertheless, IVCM is notably more effective for in-depth analysis of the epithelial phenotype and thickness than AS-OCT. http://dlvr.it/TJzttW #Cornea #Ophthalmology #Ophthotwitter

ICYMI: Cornea Update: Machine Learning–Based Identification of Risk Factors of Keratoconus Progression Using Raw Corneal Tomography Data: Purpose: The purpose of this study was to identify early indicators of keratoconus progression in Pentacam data using machine learning (ML) techniques. Methods: A retrospective Pentacam tabular data set was created by retrieving 11,760 tomography tests performed in patients with keratoconus. Data for eyes labeled unstable based on their referral for cross-linking were differentiated from data for eyes labeled stable and not referred for follow-up procedures. A boosted decision tree was trained on the final data set using a cross-validation method. Results: The final labeled data set included 1218 tomography tests. Training a ML model on a single test for each eye did not accurately predict disease progression, as indicated by the mean receiver-operating characteristic area under the curve of 0.59 ± 0.1, with precision of 0.27, recall of 0.3, and F1 score of 0.28. Training on serial tests for each eye included 819 tomography scans and yielded good prognostic abilities: a receiver-operating characteristic area under the curve of 0.75 ± 0.07, precision of 0.32, recall of 0.67, and F1 score of 0.43. In addition, 4 of the 55 Pentacam raw data parameters predominantly used the algorithm decision: age, central keratoconus index, Rs B, and D10 mm pachy. Conclusions: This study revealed specific dominant parameters attributing to the classification of stability, which are not routinely assessed in determining progression in common practice. Using ML techniques, keratoconus deterioration was evaluated algorithmically with training on multiple tests, yet was not predicted by a single tomography test. Hence, our study highlights novel factors to the current consideration of cross-linking referral and may serve as a supportive tool for clinicians. http://dlvr.it/TJyDNr #Cornea #Ophthalmology #Research

ICYMI: Cornea Update: Interpretable Machine Learning–Based Risk Score for Predicting 10-Year Corneal Graft Survival After Penetrating Keratoplasty and Deep Anterior Lamellar Keratoplasty in Asian Eyes: Purpose: To predict 10-year graft survival after deep anterior lamellar keratoplasty (DALK) and penetrating keratoplasty (PK) using a machine learning (ML)-based interpretable risk score. Methods: Singapore Corneal Transplant Registry patients (n = 1687) who underwent DALK (n = 524) or PK (n = 1163) for optical indications (excluding endothelial diseases) were followed up for 10 years. Variable importance scores from random survival forests were used to identify variables associated with graft survival. Parsimonious analysis using nested Cox models selected the top factors. An ML-based clinical score generator (AutoScore) converted identified variables into an interpretable risk score. Predictive performance was evaluated using Kaplan–Meier (KM) curves and time-integrated AUC (iAUC) on an independent testing set. Results: Mean recipient age was 51.8 years, 54.1% were male, and majority were Chinese (60.0%). Surgical indications included corneal scar (46.5%), keratoconus (18.3%), and regraft (16.2%). Five-year and ten-year KM survival was 93.4% and 92.3% for DALK, compared with 67.6% and 56.6% for PK (log-rank P < 0.001). Five factors were identified by ML algorithm as predictors of 10-year graft survival: recipient sex, preoperative visual acuity, choice of procedure, surgical indication, and active inflammation. AutoScore stratified participants into low-risk and high-risk groups—with KM survival of 73.6% and 39.0%, respectively (log-rank P < 0.001). ML analysis outperformed traditional Cox regression in predicting graft survival beyond 5 years (iAUC 0.75 vs. 0.69). Conclusions: A combination of ML and traditional techniques identified factors associated with graft failure to derive a clinically interpretable risk score to stratify PK and DALK patients—a technique that may be replicated in other corneal transplant programs. http://dlvr.it/TJyDN1 #Cornea #Ophthalmology #Research

Cornea Update: Assessment of Corneal Crosslinking for the Treatment of Corneal Neovascularization With and Without Associated Infection: Purpose: To evaluate investigational use of corneal crosslinking (CXL) to treat corneal neovascularization (CNV) with or without concomitant infection. Methods: This prospective, single-center study assessed investigational use of epithelium-off CXL with 0.1% riboflavin/20% dextran ophthalmic solution to treat various scenarios of CNV with standard 30-minute or accelerated 10-minute irradiation. Results: The CXL treatment was investigated for 38 CNV scenarios in 37 eyes of 35 participants (2 bilateral) and was repeated once in 2 eyes and twice in 1 eye. Treatment was considered successful in 24 cases, partially successful in 1 case, and unsuccessful in 8 cases; 2 cases were lost to follow up and 3 developed complications unrelated to the CXL that precluded efficacy evaluation. The CXL was considered successful in all 4 cases treated for CNV with melting and/or cheese wiring of the recipient cornea postkeratoplasty, in 7 of 9 cases with active infection, in 5 of 10 cases treated in conjunction with penetrating keratoplasty, in 3 of 4 cases treated in conjunction with lamellar keratoplasty or wound revision, and in 6 of 11 cases without associated infection or surgery. Conclusions: Investigational use of CXL can contribute to CNV regression in the following scenarios: postkeratoplasty corneal melting and suture cheese wiring, infectious keratitis, and combined with keratoplasty. However, it has limited, if any, benefit in treating CNV in situations where the stimulus for CNV is not eliminated, such as ongoing infection or chronic conditions such as limbal stem cell dysfunction. http://dlvr.it/TJy2mV #Cornea #Ophthalmology #Ophthotwitter

Cornea Update: Cyanoacrylate Glue Patch for Corneal Melting in Keratoprosthesis: Purpose: To report clinical outcomes of cyanoacrylate glue patches in managing corneal melting in keratoprosthesis (KPro). Methods: Multicenter, retrospective, noncontrolled, interventional case series. Subjects underwent cyanoacrylate glue patches for corneal melt after KPro implantation, regardless of the underlying cause, KPro design, or melt severity. Clinical success was defined as resolving aqueous leak, halting further corneal melting, and avoiding KPro or carrier corneal graft exchange for at least 12 months after cyanoacrylate glue patch application. Results: Sixteen eyes of 15 patients with KPro underwent a cyanoacrylate glue patch for corneal melting. The mean time from KPro implantation to the development of corneal melt was 49.2 months. Implanted KPro models included Lucia (37.5%) and Boston type 1 with titanium (31.2%) or polymethylacrylate backplate (31.2%). Underlying etiologies for KPro implantation included recurrent graft rejection (56.2%), autoimmune disease (31.2%), and chemical injury (12.5%). A combined procedure with a cyanoacrylate glue patch and amniotic membrane transplantation was performed in 2 cases. The criteria for clinical success were met in 87.5% of patients, with only 2 eyes (12.5%) exhibiting clinical failure. Glue patches were retained successfully for a mean time of 25.50 ± 23.87 months (range: 0–84 months). Conclusions: Cyanoacrylate glue patches provide a simple, safe, cost-effective, and effective treatment for corneal melts in patients with KPro. http://dlvr.it/TJy2mQ #Cornea #Ophthalmology #Ophthotwitter

Cornea Update: Epidemiology of Corneal Ulcers Diagnosed in the Emergency Department in California: Purpose: To determine the incidence, seasonality, geographic distribution, and risk factors for emergency department presentations with corneal ulcers and perforated corneal ulcers. Methods: Retrospective, population-based cohort study of corneal ulcers in California from 2012 to 2021. Overall and stratified yearly incidence rates, seasonality, individual-level and postal code-level risk factors for perforation, and geographic clustering were evaluated. Results: This study included 31,019 emergency department (ED) visits for corneal ulcers, with 263 cases coded as perforated corneal ulcers. The average yearly incidence was 7.94 (95% confidence interval, 7.85–8.03) per 100,000 people for ED-diagnosed corneal ulcers and 0.67 (95% confidence interval, 0.59–0.76) per 1,000,000 people for perforated corneal ulcers. Male patients, Black patients, and primary English-speaking patients had the highest incidences across sociodemographic groups. For ED-diagnosed corneal ulcers, the incidence was highest among individuals aged 20 to 60 and for perforated corneal ulcers the incidence was highest among individuals over age 75. Significant geographic clustering was observed, with hotspots in the Central Valley and inland Northern and Southern California. Visits were seasonal, with incidence peaking in July and lowest in February. Increasing age, Spanish as a preferred language, and having health insurance were significant risk factors for presenting with a perforated corneal ulcer. Indicators of low socioeconomic status were associated with higher rates of corneal ulcers. Conclusions: The incidence of ED-diagnosed corneal ulcers in California increased over the study period with a notable seasonal pattern. Higher rates were observed in Black individuals and in areas with lower socioeconomic status, providing evidence of health disparities and identifying potential targets for public health interventions. http://dlvr.it/TJy2m7 #Cornea #Ophthalmology #Ophthotwitter