Purpose: To assess the visual outcome and complications following retropupillary-fixated iris-claw intraocular lens (IOL) implantation. Methods: For this retrospective, non-comparative study, chart review of patients who underwent retropupillary iris-claw IOL implantation for the correction of aphakia from July 2014 to October 2018 and had a minimum postoperative follow-up of 2 months was carried out. Postoperative corrected distance visual acuity (CDVA), intraocular pressure (IOP), and complications were noted. Results: One hundred and twenty-two eyes of 122 patients (mean follow-up: 7.48 ± 5.2 months, range, 2 months-3.5 years) were enrolled in the study. The mean logMAR CDVA improved from 1.36 ± 0.52 preoperatively to 0.5 ± 0.42 postoperatively, at the last follow-up visit (P < 0.0001). The final CDVA improved in 110 eyes (90.2%), remained unchanged in 8 eyes (6.6%), and worsened in 4 eyes (3.3%). In cases of pre-existing cystoid macular edema (CME) or excessive intraoperative manipulations, 0.05 ml of 4 mg intravitreal triamcinolone acetonide (IVTA) was injected at the end of the surgery. Twenty eyes (16.4%) had transient ocular hypertension (OHT), 6 eyes (4.9%) had persistent OHT, and 2 eyes (1.6%) progressed to glaucoma. Choroidal detachment was noted in 2 eyes (1.6%), CME in 6 eyes (4.9%), 2 eyes (1.6%) had retinal detachment, 20 eyes (16.4%) had significant ovalization of pupil, 8 eyes (6.6%) had one haptic disenclavation, 1 eye (0.8%) had corneal decompensation, and 1 eye (0.8%) had endophthalmitis. Conclusions: Retropupillary iris-claw IOL provides good visual rehabilitation with a few complications. Its ease of insertion and short surgical time makes it a good option to correct aphakia in patients with an inadequate capsular support.

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Purpose: To determine the effect of smoking on tear stability and ocular surface of the cornea among students aged between 19 and 25 years. This study also aimed to find a correlation between tear film stability with a score of McMonnies Dry Eye Questionnaire (MDEQ) and Ocular Surface Disease Index Questionnaire (OSDI). Methods: This is a prospective, non-interventional, comparative study of 59 male (27 smokers and 32 non-smokers) undergraduates of a public university. Tear film stability was evaluated using non-invasive tear break-up time and fluorescein tear break-up time. Corneal staining was determined using Efron grading scale. MDEQ and OSDI Questionnaires were used to assess dry eye symptoms. Data were obtained from the right eye only and analyzed using descriptive and correlation analysis. Results: The age range of the participants was between 19 and 25 years. The mean age for smokers and non-smokers was 22.19 ± 2.20 and 21.22 ± 1.83 years, respectively (P = 0.07). The smoker group had statistically significant lower tear film stability than the non-smoker group (P < 0.0001). Corneal staining was statistically significant higher at the nasal and temporal parts of the cornea in smokers (P < 0.05). There was a moderate correlation between tear film stability and scores of MDEQ and OSDI. Conclusions: Tobacco smoke has a significant effect on the tear film stability, seen in reduced tear stability values among smokers. Corneal staining was found to be more extensive in the smokers. These findings would be useful to eye-care providers in the management of their dry eye patients related to smoking.

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Purpose: To study the clinico-microbiological profile and outcomes of infectious keratitis (IK) at a tertiary eye care center in North India. Methods: This is a retrospective, hospital-based, cross-sectional study. One thousand seven hundred and eighty-six corneal microbiological reports were identified from January 2017 to December 2018, out of which 625 patients of IK fulfilled the inclusion criteria. They underwent microbiological examination which included corneal scrapings, culture, and antibiotic sensitivity. Demographic features, signs and symptoms, risk factors such as associated trauma, previous ocular surgery, and use of corticosteroids were also recorded. Results: Of the 625 patients, 68.2% were male and 31.8% were female. The age group affected most was the sixth decade; 21.9% (137 cases). Trauma was the most common associated risk factor in 151 cases (24.2%) followed by previous ocular surgery in 111 (17.8%). Out of the 625 corneal scrapings, 393 (62.9%) were culture-positive. Bacterial culture accounted for 60.6% (238/393) and fungal cultures were 143 (36.4%). More than 50% of the bacterial keratitis cases and more than 60% of the fungal cases had a favorable outcome. Staphylococcus sp. and Fusarium sp. were the most common bacteria and fungus isolated, respectively. Only one-third of the cases required surgical intervention, and the remaining two-thirds were managed medically. Conclusions: In the current study, cultures were positive in 63% of cases, and the majority of cases had bacterial growth. Surgical intervention was needed in one-third of the cases. Management of corneal infections is incomplete without a good microbiological workup. Ophthalmologists should be encouraged to learn and practice basic staining procedures, and this should start early in the training years.

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Purpose: To assess digital eye strain (DES) among schoolchildren during lockdown. Methods: An online questionnaire-based, cross-sectional study was conducted. A validated, self-administered, electronic questionnaire was circulated among students of 5–18 years of age. The duration of data collection was from May 18, 2020 to May 24, 2020. Rasch-based Computer-Vision Symptom Scale was deployed to measure the DES. Results: A total of 654 students (mean age: 12.02 ± 3.9 years) completed the survey. The average per day digital device exposure was 5.2 ± 2.2 h. A total of 507 (92.8%) children reported experiencing at least one asthenopic/dry eye symptom (AS/DS). The most prevalent symptoms were eye redness (69.1%) and heaviness of eyelids (79.7%). Significant positive correlation was reported between age and per day duration of digital device exposure (Pearson correlation 0.25; P < 0.001). Computer vision syndrome (CVS) score for spectacle users was significantly higher (P < 0.001). CVS score was found to correlate significantly with age and duration of digital device exposure (P < 0.001). Conclusion: Most of the students surveyed, experienced at least one symptom of DS or AS, indicating a need to educate them about the possible deleterious effects and help them adapt to the currently evolving education system.

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Purpose: To evaluate the multimodal imaging of acute syphilitic posterior placoid chorioretinitis (ASPPC) lesions in order to elucidate their pathophysiology which seems to resemble choriocapillaritis as in primary inflammatory choriocapillaropathies such as multifocal choroiditis (MFC) and acute posterior multifocal placoid pigment epitheliopathy (APMPPE). Methods: Charts of patients with ASPPC seen in the Centre for Ophthalmic Specialised Care, Lausanne, Switzerland, were retrieved. Fundus autofluorescence (FAF), spectral domain optical coherence tomography (SD-OCT), fluorescein angiography (FA), indocyanine green angiography (ICGA), and when available, OCT angiography were analyzed and compared to a case of MFC. Results: One woman aged 58 and 2 men aged 50 and 31 with unilateral ASPPC were analyzed. All had positive syphilis serologies (venereal disease research laboratory [VDRL] and treponema Pallidum hemagglutination assay [TPHA]). Two were human immunodeficiency virus (HIV) positive. Mean best corrected visual acuity was 0.2 ± 0.1 at presentation and 1.0 for all patients 6 weeks later, after antibiotic treatment for neurosyphilis. All had central scotomata with a mean defect (MD) of 12.2 ± 2.6. Six weeks later, MD values were 3.9 ± 1.7. Microperimetry had a mean score of 25/560 at presentation and recovered to a mean of 444/560 6 weeks later. Multimodal imaging features consisted of FA tissue staining, ICGA hypofluorescent choriocapillaris non-perfusion, FAF hyperautofluorescence, and loss of the ellipsoid line in the diseased areas. The findings were consistent and identical in ASPPC and a case of MFC and pointed toward the involvement of the choriocapillaris. Conclusions: Similarities seen in multimodal imaging features in ASPPC and choriocapillaritis highlight the role of the choriocapillaris in the pathophysiologic mechanism of both conditions. Inflammatory choriocapillaris non-perfusion triggered by infectious agents seems to be the common pathway through which the eye is reacting.

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Purpose: It is crucial to subdivide Vogt–Koyanagi–Harada (VKH) disease into two subentities, initial-onset disease versus chronically evolving disease. For early diagnosis and precise follow-up of VKH choroiditis, the “Revised criteria for VKH” are no more sufficient for the appraisal of VKH and new biomarkers for disease activity are needed. It has been shown that, if initial-onset disease is treated promptly within the “therapeutic window of opportunity” and long enough with dual steroidal and non-steroidal immunosuppression, the disease can be cured in a large proportion of cases, an approach still contested. The proportion of chronic evolution and/or sunset-glow fundus (SGF) following steroidal monotherapy versus dual steroidal and non-steroidal immunosuppression was compared. Methods: A literature search was performed, identifying studies on initial-onset VKH treated either by steroidal monotherapy or dual immunosuppression. Evolution toward chronicity and/or SGF was compared in both groups. Results: Twenty studies were identified with reported long-term outcomes. In 16 studies, 802 patients received steroidal monotherapy, while in 4 studies, 172 patients received dual steroidal and non-steroidal immunosuppression. Chronic evolution and SGF occurred, respectively, in 44% and 59% in the corticosteroid-alone group versus 2.3% and 17.5% in the dual therapy group with no chronic evolution in three studies and no SGF in two studies. Conclusions: Chronic evolution and SGF are significantly less frequent in initial-onset VKH when treated with immediate dual steroidal and non-steroidal immunosuppression with a high proportion of healed cases. This combined approach seems recommended in the management of initial-onset VKH disease.

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Purpose: To report two cases of typical multiple evanescent white dot syndrome (MEWDS), in which swept-source optical coherence tomography angiography (SS-OCTA) revealed transient areas of flow deficit at the level of the choriocapillaris. Methods: The SS-OCTA images of two female patients with typical MEWDS were analyzed at the onset of the disease and during follow-up. Results: The patients were aged 24 and 25 years, respectively. Previous medical history was unremarkable in both cases. The diagnosis of MEWDS was made on the basis of typical clinical findings and results of fundus autofluorescence, fluorescein angiography, and optical coherence tomography. At presentation, SS-OCTA showed a few small hypointense areas of flow deficit at the level of the choriocapillaris in both cases. During follow-up, SS-OCTA showed complete resolution of choriocapillaris flow voids. Conclusion: Both our patients with typical acute MEWDS showed SS-OCTA multifocal small areas of flow reduction at the level of the choriocapillaris, with full recovery during the follow-up. This finding supports the hypothesis of transient, primary, or secondary choriocapillaris hypoperfusion in typical MEWDS.

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Purpose: To review the diagnostic criteria for Tolosa–Hunt syndrome (THS) and utility of recent modifications. Methods: We searched PubMed for keywords Tolosa Hunt and magnetic resonance imaging. We compared the three editions of International Classification of Headache Disorders and isolated case reports and case series with the assessment of cavernous internal carotid artery (ICA) caliber to find the prevalence of vascular anomalies. We also evaluated cases of THS with the involvement of extracavernous structures and the possible role of idiopathic hypertrophic pachymeningitis (HP). Cases diagnosed falsely as THS were also reviewed for the presence of atypical features and relevance of criterion D. We assessed nonconforming cases (those with normal neuroimaging benign THS) and idiopathic inflammatory orbital pseudotumor (IIPO). Results: Vascular abnormalities were found in 36.36% of THS cases. Benign THS may also show changes in ICA caliber. Evidence suggestive of idiopathic HP could be found in 57% of cases with the involvement of extracavernous structures, such as facial nerve and pituitary gland. Both THS and IIPO are steroid-responsive pathologies with similar clinical and radiological features. False-positive diagnosis of THS results from early labeling, based solely on clinical features and symptom resolution after steroid therapy. Conclusions: Benign THS may be a result of limitation of resolution of available neuroimaging technique or early testing. Early and late vascular changes can be seen in both THS and its benign variant; some of them are not innocuous. THS may be considered a type of focal idiopathic HP. IIPO may represent an anterior variant of THS. In the absence of histopathological diagnosis, steroid-induced resolution of symptoms should be confirmed radiologically and followed-up.

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Purpose: To discuss the ocular manifestations provoked by novel coronavirus 2019 (COVID-19) disease in humans, the natural history of the disease in the eye, and its treatment. Methods: We designed a narrative review of the ocular manifestations of COVID-19 based on the literature published till July 30, 2020. The databases were PubMed, Scopus, Cochrane Library, Google Scholar, and ScienceDirect. The inclusion criteria were (1) all types of clinical studies and (2) the topic was COVID-19 and its association to the eye regarding the current guidelines. Results: From 168 abstracts screened, 61 papers fully filled the inclusion criteria after the full-text screening. The 61 records include 13 case reports, 17 prospective (case series or cross-sectional) studies, 8 retrospective studies, 12 literature reviews (one systematic review), and 11 letters to the editor. The majority of the papers agreed that ophthalmic manifestations due to COVID-19 were few and rarely encountered. The main ocular pathology seemed to be conjunctivitis, where the viral polymerase chain reaction also happened to be most detectable. Posterior segment or neuro-ophthalmic manifestations were scarce. Viral genome detection in the eye as well as viral portal of entry to the globe is still vague. Conclusion: The exact incidence of ocular manifestations in COVID-19 disease is uncertain. Conjunctivitis is the most prevalent ocular manifestation. It is still a debate whether the eye is a portal of entry for infection.

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Purpose: To describe the multicolor imaging (MCI) features in a series of patients diagnosed with a choroidal nevus and compare it vis-à-vis color fundus photography (CFP) in identifying the lesion. Methods: In this retrospective, descriptive case series at a tertiary referral center in South India, all patients diagnosed with the choroidal nevus underwent CFP, optical coherence tomography, MCI, and infrared reflectance (IR) imaging. Results: In this study, we found that on MCI, the choroidal nevus could be identified in only six of the 12 eyes. The lesions were seen as an area of hyperreflectance on IR image and orange-colored lesion on multicolor image. In one eye, there was a mixed pattern of hyper and hyporeflectance on IR imaging. The remaining five eyes with choroidal nevus lesions were not identified on MCI. Conclusion: The variable features of the choroidal nevus on MCI are most likely due to the variable melanin content within the nevus cells. Further studies are needed to validate these findings.

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Purpose: To report clinical features, pathology characteristics, and treatment outcomes of five patients with Rosai-Dorfman disease (RDD). Methods: A retrospective case series of patients with RDD from the Ocular Oncology Service of Wills Eye Hospital between 1974 and 2018. Results: There were six eyes of five patients (3 males, 2 females) with ophthalmic manifestations of RDD. The mean age at the initial presentation was 33 years (median 35, range 10–52 years). Before referral, the tumor was initially suspected to be lymphoma (n = 3), idiopathic orbital inflammation (n = 2), or pterygium (n = 1). The disease was unilateral (n = 4) or bilateral (n = 1). The mean duration of symptoms was 9 months (median 8, range 5–24 months). The disease produced nodules in the conjunctiva (n = 4) or orbit (n = 2). Two patients with conjunctival involvement had corneal involvement. One patient with bilateral conjunctiva lesions demonstrated bilateral orbital involvement and bilateral anterior uveitis. The mean tumor basal dimension was 13 mm (median 9, range 6–27 mm) for conjunctiva lesions and 37 mm (median 37, range 34–40 mm) for orbital lesions. The main symptom (per patient) included proptosis (n = 2), palpable mass (n = 1), and foreign body sensation (n = 2). No patient experienced pain or tenderness. Palpable, nontender lymphadenopathy was detectable in two patients in the cervical and inguinal lymph nodes. Systemic involvement with paranasal sinusitis and mediastinal/pulmonary lymphadenopathy occurred in two patients, both with orbital involvement. Surgical resection was performed for all patients. At a mean follow-up of 31 months (median 12, range, 10–76 months) after the surgery, tumor control was achieved in all six eyes without local recurrence. Conclusion: In this series of six eyes with RDD, patients with orbital and/or intraocular disease were more likely to demonstrate lymphadenopathy and systemic involvement, while those with unilateral perilimbal conjunctival tumors remained localized.

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Purpose: To evaluate the efficacy of intravitreal bevacizumab (IVB) combined with intravitreal methotrexate (IVM) in the treatment of diabetic macular edema (DME). Methods: In this prospective, interventional contralateral eye study, patients with bilateral DME were randomly allocated to receive three monthly injections of IVB (1.25 mg/0.05 mL) plus IVM (400 μg; 0.16 cc) or IVB alone. The outcome measure was changes in the best corrected visual acuity (BCVA), central macular thickness (CMT), and central macular volume (CMV). Results: Thirty-six treatment-naive eyes of 18 patients with a mean age of 62.38 ± 6.2 years were included in the study. BCVA logMAR changed from 0.95 ± 0.53 at baseline to 0.75 ± 0.53 in the combination group and from 0.72 ± 0.57 to 0.49 ± 0.50 in the IVB alone group at 1 month after the 3^rd injection. BCVA improvement in both groups was not statistically significant compared with the baseline value (P > 0.99). Compared with the baseline values, mean CMT and CMV were reduced in both groups; however, these changes did not reach a significant level. The differences of CMT changes between the groups were not statistically significant at month 1 (P = 0.82), month 2 (P = 0.21), and month 3 (P = 0.10). Furthermore, the differences of CMV changes between the groups were not statistically significant at month 1 (P = 0.76), month 2 (P = 0.82), and month 3 (P = 0.11). Conclusions: This pilot study demonstrated no significant therapeutic effects for IVB combined with IVM compared to IVB alone in treatment-naive DME patients over a 3-month course.

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Purpose: To report the limbal allograft transplantation and penetrating keratoplasty (PK) results in limbal stem cell deficiency (LSCD)-developed eyes because of chemical or thermal injury. Methods: Medical records of 18 eyes of 14 patients who had undergone keratolimbal allograft (KLAL) or living-related conjunctival limbal allograft (lr-CLAL) with or without PK and followed up at least 1 year postoperatively were evaluated retrospectively. The preoperative LSCD grade was noted in all patients. Rejection incidents, recurrence of LSCD, and corneal graft clarity along with a visual improvement during the follow-up were noted. The complications rate due to surgery or injury itself, for instance, glaucoma and cataract, were evaluated. The limbal allograft tissue survival analysis and corneal allograft survival analysis were done to reveal the differences in both the procedures. The existence of normal corneal epithelium and improvement in visual acuity were accepted as the surgical success criteria. Results: In the limbal allograft transplantation group, the survival rates of the allograft tissue were 65 ± 10.7% at 1 year and 36.6 ± 11.4% at 3 years in lr-CLAL and 66.7 ± 15.7% at 12 months and 53.3 ± 17.3% at 18 months in KLAL-transplanted eyes. The survival rate of corneal allograft at the 5^th postoperative year was lower in the simultaneous procedure compared to the staged procedure, but it was not statistically significant (25.7 ± 25.8% vs. 62.5 ± 17.1%, P = 0.75). The ambulatory vision was achieved in 10 eyes (56%) after a mean follow-up time of 93.8 ± 37.8 months. The visual acuity level has increased in 12 eyes (67%) in which the limbal allograft transplantation was applied. The ambulatory visual acuity level was achieved (≤1.0 logMar [20/200]) in 10 eyes (56%). In addition, two or more Snellen lines' gain in the best corrected visual acuity was observed in 12 eyes of 18 (67%) at the last follow-up, and there was not any significant difference between the KLAL and lr-CLAL. Conclusions: Ocular surface integrity was longer in KLAL than in lr-CLAL transplantation, but it was not statistically significant. The staged procedure was more convenient than the simultaneous procedure in terms of corneal allograft clarity maintenance in limbal allograft-employed eyes.

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Purpose: To assess the possible association between keratoconus (KC) and serum levels of 25-hydroxyvitamin D (25OHD), Selenium (Se), Zinc (Zn), and Copper (Cu) and to compare it with age-matched healthy subjects. Methods: One hundred patients with KC and 100 normal subjects were included. The two groups were compared for serum 25OHD and serum levels of three trace elements: Se, Zn, and Cu. These factors were also compared between groups with different KC stages. Results: Serum levels of vitamin D, Zn, Cu, and Se were significantly different between the KC and normal groups (P = 0.006, P = 0.015, P = 0.004, and P = 0.038, respectively). Although a lower level of 25OHD was found in severe stages of KC, it was not significantly different among different KC groups (P = 0.441). KC stage groups were not significantly different for mean serum Zn, Cu, and Se (P = 0.130, P = 0.98, P = 0.113, respectively). Although the Cu/Zn ratio was higher in cases than in controls, there was no significant difference between the two groups and between KC stages (P = 0.168, P = 0.143, respectively). Conclusion: Lower serum 25OHD, Cu, Zn, and Se were found in the KC group compared to the control group. The results of this study suggest that a lower antioxidative activity may be involved in the possible etiology of KC.

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Purpose: To review current non-surgical management methods of intermittent exotropia (IXT) which is one of the most common types of childhood-onset exotropia. Methods: A search strategy was developed using a combination of the words IXT, divergence excess, non-surgical management, observation, overcorrecting minus lens therapy, patch/occlusion therapy, orthoptics/binocular vision therapy, and prism therapy to identify all articles in four electronic databases (PubMed, Web of Science, Google Scholar, and Scopus). To find more articles and to ensure that the databases were thoroughly searched, the reference lists of the selected articles were also reviewed from inception to June 2018 with no restrictions and filters. Results: IXT is treated when binocular vision is impaired, or the patient is symptomatic. There are different surgical and non-surgical management strategies. Non-surgical treatment of IXT includes patch therapy, prism therapy, orthoptic sessions, and overcorrecting minus lens therapy. The objective of these treatments is to reduce the symptoms and the frequency of manifest deviation by decreasing the angle of deviation or enhancing the ability to control it. Conclusions: Evidence of the efficacy of non-surgical management options for IXT is not compelling. More comprehensive randomized controlled trial studies are required to evaluate the effectiveness of these procedures and detect the most effective strategy.

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Purpose: To review the clinical features, diagnosis, treatment modalities, and prognosis of arthropod-borne infectious diseases. Methods: This is a narrative review on arthropod-borne infectious diseases including general and ophthalmological aspects of these infectious diseases. A comprehensive literature review between January 1983 and September 2020 was conducted in PubMed database. Epidemiology, clinical features, diagnosis, treatment, and prognosis of arthropod-borne infectious diseases were reviewed. Results: Emergent and resurgent arthropod-borne infectious diseases are major causes of systemic morbidity and death that are expanding worldwide. Among them, bacterial and viral agents including rickettsial disease, West Nile virus, Dengue fever, Chikungunya, Rift valley fever, and Zika virus have been associated with an array of ocular manifestations. These include anterior uveitis, retinitis, chorioretinitis, retinal vasculitis, and optic nerve involvement. Proper clinical diagnosis of any of these infectious diseases is primarily based on epidemiological data, history, systemic symptoms and signs, and the pattern of ocular involvement. The diagnosis is confirmed by laboratory tests. Ocular involvement usually has a self-limited course, but it can result in persistent visual impairment. Doxycycline is the treatment of choice for rickettsial disease. There is currently no proven specific treatment for arboviral diseases. Prevention remains the mainstay for arthropod vector and zoonotic disease control. Conclusions: Emerging arthropod vector-borne diseases should be considered in the differential diagnosis of uveitis, especially in patient living or with recent travel to endemic countries. Early clinical diagnosis, while laboratory testing is pending, is essential for proper management to prevent systemic and ocular morbidity.

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Purpose: To present a rare case report of Onodi cell-associated optic neuropathy, conducting a review of the literature. Methods: A 36-year-old male presented with an 18-h history of acute deterioration of vision in his left eye (LE). Ophthalmic examination and Magnetic Resonance Imaging (MRI) were consistent with an Onodi cell-associated compressive optic neuropathy. Results: Despite immediate, successful surgical decompression, severe optic nerve atrophy and permanent visual loss occurred during early postoperative period. The reported case gives rise to different hypotheses regarding pathophysiology that may lead to irreversible blindness. A systematic review of the respective literature is provided attempting to compare different approaches in the management of Onodi cell-associated compressive optic neuropathy and assess their efficacy in the final visual outcome. Poor initial visual acuity (VA) may represent a bad prognostic factor. Moreover, age and gender do not seem to significantly influence the outcome. Conclusion: This report and associated literature review highlight the importance of the radiologic characteristics and early diagnosis in the final visual outcome of the Onodi cell-associated optic neuropathy. High level of suspicion is crucial for early diagnosis of mucoceles, which must be treated promptly by surgical and medical means to enhance visual recovery.

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Purpose: To evaluate the multiple pretreatment characteristics and topographic factors of keratoconus (KC) patients and their relationship to clinical outcomes of corneal collagen cross-linking (CXL). Methods: In this prospective study, 61 patients (106 eyes) with KC as candidates for CXL were included. Demographic data including age, sex, place of birth and residence, atopic constitution, family history, rubbing history, sleep apnea, and blood group were collected via a structured checklist. Complete ophthalmologic examination and tear collection to assess tear interleukin 6 (IL-6) and tumor necrosis factor alpha (TNF-α) level were performed. Topometric parameters were evaluated using a rotating Scheimpflug topography device. Changes in best corrected visual acuity (BCVA) and maximum keratometry (K-max) were considered the main predicted variables. Predictive variables were analyzed by univariate and multivariate regression. Results: The use of multivariate analysis changes in K-max was significantly associated with rubbing frequency (coefficient = 0.94, P = 0.02), blood group (coefficient = 4.52, P = 0.005), pretreatment corneal asphericity (coefficient = −3.99, P ≤ 0.001), and pretreatment central keratoconus index (CKI) (coefficient = −55.38, P = 0.001). Regarding the changes in BCVA, the multivariate analysis showed a significant association with place of birth (coefficient = −0.08, P = 0.03), pretreatment BCVA (coefficient = −0.67, P < 0.001), pretreatment central corneal thickness (CCT) (coefficient = −0.005, P = 0.04), and pretreatment keratoconus index (KI) (coefficient = 0.53, P = 0.04). Other parameters assessed in the multivariable analysis did not appear to have an individual effect on treatment outcomes. Conclusion: Our results demonstrated that blood group, rubbing of eye, place of birth, corneal asphericity, pretreatment BCVA, CKI, KI, and CCT were statistically associated with the outcome of KC following CXL.

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Purpose: To present the management of upside-down Descemet membrane endothelial keratoplasty (DMEK) following combined phacoemulsification with DMEK (phaco-DMEK) in cases of Fuchs endothelial dystrophy (FED). Methods: This is a comparative interventional case series extracted from a prospective interventional case series (clinical outcome of DMEK combined with phacoemulsification for FED). We report five cases of upside-down DMEK. Two cases of upside-down DMEK were managed with re-orientation and the other two with repeat DMEK. The 5^th case underwent an initial re-orientation and then a subsequent repeat graft. Graft re-orientation and repeat surgery were performed 9–20 days after initial phaco-DMEK. All the five cases were followed up over a 6-month period, and the following outcomes were assessed: best corrected visual acuity (BCVA), contrast sensitivity (CS), central corneal thickness, endothelial cell density (ECD), and central macular thickness. Results: At the final 6-month postoperative follow-up, all the five cases achieved good outcomes in terms of BCVA and CS. Overall, the results were comparable to 32 control cases. One case of re-orientation and the case of re-orientation with subsequent repeat DMEK performed slightly less well than control cases in terms of postoperative ECD. Conclusions: Re-orientation of the original DMEK scroll in cases of upside-down DMEK can be a safe and cost-effective alternative to repeat DMEK. If re-orientation does not result in corneal deturgescence, a repeat DMEK may be done subsequently.

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Purpose: To determine economic inequality in unmet refractive error (RE) need and its determinants in deprived rural population of Iran. Methods: In this population-based study, two villages were randomly selected from among underserved villages of Iran. After selecting the participants, optometric examinations, including uncorrected and corrected visual acuity and subjective and manifest refraction, were done for all the participants. Then, unmet need for glasses was determined. Concentration index (C) was used to assess inequality, and Oaxaca–Blinder decomposition method was applied to decompose the gap between the two groups based on the determinants. Results: Of 3851 samples, 3314 participated in the study (response rate = 86.05%). The data of 3255 participants were used for analysis. The value of C and 95% confidence interval (CI) was −0.088 (−0.157 to −0.020), indicating a pro-poor inequality in unmet need. The prevalence (95% CI) of unmet need was 11.74% (9.25–14.22) in the poor and 6.51% (4.96–8.06) in the rich, with a gap of about 5% in favor of the rich (P < 0.001). A marked percentage of the gap was due to the explained portion (b = 5.73; P = 0.031). In the explained portion, the variable of economic status (b = 3.48; P = 0.004) and myopia (b = 0.88; P = 0.031) caused inequality in favor of the rich and against the poor, respectively. In the unexplained portion (b = −0.51; P = 0.372), the variables of education (P = 0.002) and place (P = 0.001) had statistically significant effects on inequality. Conclusions: There is a significant pro-poor economic inequality in the prevalence of unmet need in rural areas of Iran. Although part of this inequality is related to variables such as education and myopia, a major portion (two thirds) of this inequality may be due to the direct effect of economic inequality.

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Purpose: To report the imaging characteristics of various clinical features in idiopathic macular telangiectasia (MacTel 2) on multicolor imaging (MCI) and compare its accuracy vis-à-vis color fundus photograph (CFP) and fluorescein angiography (FA). Methods: In this retrospective observational study, 54 eyes of 27 patients with MacTel 2 were included after institutional review board approval. Multimodal imaging with CFP, optical coherence tomography (OCT), MCI, and FA was done. Images were analyzed to identify and describe the clinical findings in MacTel 2. Sensitivity, specificity, and positive and negative predictive values were computed for the various imaging modalities in MacTel 2. Results: In this study, the MCI identified all the different clinical features of MacTel 2 in 100% of cases. The confocal blue reflectance (BR) image was more sensitive than CFP (100% vs. 96.3%) in identifying the loss of retinal transparency in MacTel 2. For other clinical features such as right-angled vessels, superficial retinal crystals, and retinal pigment epithelial hyperplasia/plaques, the sensitivity of BR, and green reflectance (GR) image, was comparable to that of CFP. Confocal infrared reflectance (IR) images showed poor sensitivity in identifying the non-proliferative features in MacTel 2 (P < 0.001). Loss of retinal transparency was not picked up on IR image. Other features such as right-angled vessels, superficial retinal crystals, and pigment plaques were seen in 20%, 4.6%, and 26.3% of cases, respectively. However, confocal IR images were superior to FA (100% vs. 47%) and CFP (100% vs. 15%) in identifying the extent and location of subretinal neovascular membrane. The confocal BR and GR images were unable to identify the choroidal neovascular membrane (P < 0.001). Conclusion: MCI is a useful and non-invasive imaging modality to identify the clinical features in MacTel 2. MCI can be used as a complementary imaging tool to CFP, FA, and OCT.

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Purpose: To compare the effects of accelerated corneal collagen cross-linking (CXL) in progressive keratoconus (KCN) patients via epithelium removal and transepithelial techniques, using Daya Disruptor (Duckworth and Kent, Hertfordshire, UK). Methods: This study is a double-blinded, randomized clinical trial. Patients with documented bilateral progressive KCN were randomized into two groups: one eye underwent epithelium removal (Group 1), and the fellow eye underwent epithelium disruption (Group 2). The primary outcomes were best corrected visual acuity (BCVA) and uncorrected visual acuity (UCVA), Scheimpflug-extracted keratometric indices, and anterior segment-optical coherence tomography-derived epithelial thickness profiles. These parameters were evaluated before and 12 months after CXL. Results: Sixty-four eyes from 34 patients with progressive KCN (34 eyes in the epithelium-removal group and 30 eyes in the epithelium-disruption group) were included. The mean ± standard deviation (SD) of age was 23.4 ± 3.8 years in the epithelium-removal group and 23.2 ± 3.5 years in the epithelium-disruption group. The mean ± SD of the preoperative spherical equivalent (SE), front maximum keratometry (K-max), back K-max, thickness of thinnest point, and corneal apex thickness were − 2.9 ± 3.0 diopter (D) and − 3.7 ± 3.1 D (P = 0.183), 53.8 ± 5.15 D and 54.4 ± 5.53 D (P = 0.653), −6.63 ± 2.40 D and − 6.68 ± 2.48 D (P = 0.131), 459.2 ± 37.4 μm and 460.8 ± 32.7 μm (P = 0.708), 470.5 ± 37.7 μm and 469.7 ± 33.1 μm (P = 0.679), and 55.4 ± 4.97 μm and 54.6 ± 7.16 μm (P = 0.767) in the epithelium-removal and epithelium-disruption groups, respectively. The mean ± SD changes of the UCVA and BCVA 12 months after CXL were − 0.1 ± 0.11 and − 0.02 ± 0.18 and − 0.04 ± 0.12 and − 0.02 ± 0.14 in the epithelium-removal and epithelium-disruption groups, respectively. No statistically significant improvement was observed in the UCVA and BCVA between the two groups (P = 0.868 and P = 0.937, respectively). The mean ± SD changes of the SE, superior epithelial thickness, corneal apex thickness, and thickness of thinnest point 12 months after CXL were − 0.21 ± 1.1 D and + 0.32 ± 1.6 D (P = 0.0001), −0.08 ± 0.26 μm and + 0.03 ± 0.33 μm (P = 0.028), −23 ± 11 μm and − 2 ± 6 μm (P = 0.0001), and − 25 ± 8 μm and − 3 ± 7 μm (P = 0.0001) in the epithelium-removal and epithelium-disruption groups, respectively. Conclusions: This study showed that the epithelium-disruption CXL using Daya has a similar potential for halting KCN progression as the epithelium-removal CXL. However, regarding the 12-month changes, the epithelium-disruption CXL is superior to the epithelium-removal CXL in the SE and corneal pachymetry.

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Purpose: To investigate retinal layers' thickness and vascular density after successful scleral buckle surgery using the optical coherence tomography angiography (OCTA) method. Methods: In this prospective interventional case-control study, 24 patients with macular-off rhegmatogenous retinal detachment (RRD) were included after performing successful reattachment by scleral buckling. Retinal layers' thickness and vascular density were assessed in the patients using the OCTA method compared to normal fellow eyes as controls 10 months postoperation. Results: Inner retinal layers showed no significant difference, but there was a significant reduction in outer central 1-mm retinal layers' thickness. Outer plexiform-Bruch's membrane (153.1 ± 24.3 μm vs. 166.2 ± 15.1 μm, P = 0.003) and ellipsoid zone to Bruch's membrane (51.25 ± 9.3 μm vs. 57.35 ± 3.8 μm, P = 0.009) were thinner in the operated eyes compared to fellow eyes. Vascular density within a 300 μm wide region around the foveal avascular zone (FAZ) (foveal density-300) was significantly lower in the detached eyes (46.28% ± 7.12% vs. 51.01% ± 4.73%, P = 0.016), however, there was no difference in superficial and deep vascular density at 1-mm central circle. Superficial parafoveal vascular density was lower in the operated eyes (46.24% ± 5.30% vs. 49.52% ± 5.93%, P = 0.026) with no significant difference in deep parafoveal vascular density (49.93 ± 4.29% vs. 51.88% ± 4.79%, P = 0.137). There was no difference in FAZ area and perimeter between the two groups. Conclusions: Complete recovery of retinal thickness and vascular density did not achieve in the patients with RRD even after 10 months of reattachment by scleral buckling surgery. Superficial capillary vascular density was more affected than deep vascular density almost in the parafoveal area.

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Purpose: To identify and explain different artifacts in macular optical coherence tomography (OCT). Methods: For this comprehensive review, a PubMed and Google Scholar (January 1995–October 2018) search was conducted by the researchers, using the keywords such as OCT, artifacts, artefact, and macula. Results: We reviewed the main OCT artifacts including software break-down or misidentification of retinal layers, incomplete segmentation error, complete segmentation failure, mirror artifact (inverted artifact), cut edge artifact, degraded image scan, out-of-register artifact, off-center artifact, motion artifact, foveal duplication, segmentation shift, blink artifact, static or fixed image artifact, linear artifact, and perfluorocarbon liquid-producing artifact. Conclusions: There are various artifacts in OCT image scans. The identification of these artifacts may help in accurate interpretations of OCT images in clinical settings that can affect the diagnosis and management of different retinal disorders.

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Purpose: To assess the diagnostic accuracy measures such as sensitivity and specificity of smartphone-based artificial intelligence (AI) approaches in the detection of diabetic retinopathy (DR). Methods: A literature search of the EMBASE and MEDLINE databases (up to March 2020) was conducted. Only studies using both smartphone-based cameras and AI software for image analysis were included. The main outcome measures were pooled sensitivity and specificity, diagnostic odds ratios and relative risk of smartphone-based AI approaches in detecting DR (of all types), and referable DR (RDR) (moderate nonproliferative retinopathy or worse and/or the presence of diabetic macular edema). Results: Smartphone-based AI has a pooled sensitivity of 89.5% (95% confidence interval [CI]: 82.3%–94.0%) and pooled specificity of 92.4% (95% CI: 86.4%–95.9%) in detecting DR. For referable disease, sensitivity is 97.9% (95% CI: 92.6%-99.4%), and the pooled specificity is 85.9% (95% CI: 76.5%–91.9%). The technology is better at correctly identifying referable retinopathy. Conclusions: The smartphone-based AI programs demonstrate high diagnostic accuracy for the detection of DR and RDR and are potentially viable substitutes for conventional diabetic screening approaches. Further, high-quality randomized controlled trials are required to establish the effectiveness of this approach in different populations.

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