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 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 review the published data about changes in the anterior chamber depth (ACD) in keratoconus patients. Methods: In this systematic review and meta-analysis of observational studies, we reviewed the available and relevant literature on anterior segment changes in keratoconic eyes, with a special focus on the ACD, an effective factor in many surgical methods. Articles published up to December 2017 were identified in the following data sources: PubMed, Scopus, Ovid, ISI, ScienceDirect, and Google Scholar. Databases were comprehensively searched using the key words “Anterior Chamber Depth AND Anterior segment AND Keratoconus”. Results: A total of 496 studies including these key words were detected. Four hundred fifty-three studies were excluded, and overall 16 studies which precisely described the change in ACD were included in the literature review. The results show that with respect to the applied device, there was a statistically significant difference in ACD between keratoconic eyes and normal eyes except for Galilei analyzer. Conclusion: Summarizing the results of studies, this review revealed that ACD is significantly deeper in keratoconic eyes as compared with normal eyes, which could be explained by the steeper corneal curvature.

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Purpose: To evaluate the macular microvasculature in smokers in comparison to healthy subjects using optical coherence tomography angiography (OCTA). Methods: Fifty chronic, regular smokers and 50 healthy non-smokers, as a control group, were recruited for the study. Foveal avascular zone (FAZ) area (mm²) and vessel density (VD) (%) in the superficial (SCP) and deep capillary plexus (DCP) were evaluated. Results: FAZ area was 0.424 ± 0.100 mm² in the smoker group and 0.333 ± 0.093 mm² in the non-smoking control group (P = 0.002). The deep foveal VD was 31.76 ± 6.33% in the smoker group and 53.09 ± 5.88% in the non-smoking control group (P = 0.006). Superficial foveal and parafoveal, deep parafoveal VD were not statistically different between the groups (P = 0.120), (P = 0.337), (P = 0.287), respectively. Conclusion: In our study, there was an enlargement of FAZ and reduction of foveal VD at DCP in the eyes of smokers compared with non-smoking adults.

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Purpose: To investigate the choroidal thickness and its association with age, gender, spherical equivalent (SE), and axial length (AL) in a sample of Iranian population with different refractive status using spectral-domain optical coherence tomography (SD-OCT). Methods: In a cross-sectional study, a total of 469 right eyes of 469 healthy subjects comprising 194 (41.4%) males and 275 (58.6%) females were examined. The mean age was 32.76 ± 15.77 years (range, 4-60 years). All subjects were divided into different groups according to their refractive status, age, and AL. The choroidal thickness was evaluated through enhanced-depth imaging (EDI) modality at subfoveal (Sf), 1, and 3 mm nasal (N1 and N3, respectively), temporal (T1 and T3, respectively), superior (S1 and S3, respectively), and inferior (I1 and I3, respectively) to the foveal center. Results: In the whole population, the mean subfoveal choroidal thickness (SfChT) was 329.83 ± 70.33 μm, and the choroid was thickest at S1 (342.04 ± 71.28 μm) and thinnest at N3 (209.00 ± 66.0 μm). Our data indicated a significant difference in the mean choroidal thickness across all points in different age groups (P < 0.0001). For emmetropic, myopic, and hyperopic subjects, mean SfChT values were 346.64 ± 59.63, 319.66 ± 73.17, and 364.00 ± 74.54 μm, respectively. Linear regression estimated that SfChT decreased about 12.8 and 8.71 μm for every 10 years of aging and each diopter increasing in myopia, respectively. Additionally, the SfChT decreased as 13.48 μm per mm increase in AL. Conclusions: The mean SfChT of a sample of Iranian emmetropic subjects was 346.64 ± 59.63 μm. The choroidal thickness has a decreasing trend with increasing age, and the choroid is thinner in myopes and thicker in hyperopes compared with emmetropic subjects. In the whole participants, the thickest and thinnest points were S1 and N3, respectively.

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Purpose: To review various treatment methods in thyroid eye disease (TED) related strabismus. Methods: We searched in PubMed and Google Scholar and Ovid MEDLINE for keywords including TED-related strabismus, strabismus in thyroid-associated ophthalmopathy, Graves^' ophthalmopathy related strabismus or squint, and restrictive strabismus. Two expert strabismus specialists selected and evaluated the English articles that were related to our paper and had been published since 2000. Some articles were added based upon the references of the initial articles. Results: One hundred fifteen articles were found, 98 of which were mostly related to the topic of this review. Management of TED-related strabismus was reviewed and categorized in non-surgical and surgical. Botulinum toxin A (BTA) is a useful non-surgical management of strabismus in an active TED and residual deviation after strabismus surgery. Postoperative under-correction is relatively more common in TED-related esotropia. Lateral rectus resection and BTA are the options to manage the problem. Muscle rectus muscle resection should be performed after maximum recession of restricted muscles. It should be avoided on a restricted or enlarged muscle. Management of TED-related vertical deviation is challenging. In these cases, the surgical treatment selected depends on forced duction test (FDT) (pre and intraoperative), orbital imaging (which muscle is enlarged), and the amount of vertical deviation (in both down-gaze and primary position). Conclusions: TED-related strabismus needs careful evaluation and management to achieve optimal outcome. Different surgical and non-surgical options are available for intervention in TED-related strabismus.

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Purpose: To investigate the impact of glaucoma-associated vision loss on quality of life and social functioning in Indians. Methods: A cross-sectional study with prospective enrollment was conducted. Participants were divided as: mild, moderate, and severe. Severity of glaucoma was stratified by the degree of binocular visual field loss in accordance with the Nelson Glaucoma Severity Scale (NGSS). The Glaucoma Quality of Life-15 (GQL-15) and a self-developed social function scale (SFS) were utilized to assess patients' wellbeing. Results: A total of 260 patients (mean ± SD age = 58.1 ± 12.01 years; 106 females) participated in the study. Univariate analyses revealed a significant relationship between final quality of life score and number of anti-glaucoma medications (P = 0.01), previous surgeries (P = 0.00), patients age (P = 0.00), patients education level (P = 0.02), and severity of glaucoma (P = 0.00). Previous surgeries (P = 0.04) and severity of glaucoma (P = 0.00) were significant predictors of GQL-15 summary score. With increasing glaucoma severity, patients noted greater difficulty with peripheral vision, glare and dark adaptation, and outdoor tasks (P < 0.0001). Severe glaucoma also impacted patients' functional performance—a significant decline was observed in sense of personal (P < 0.0001) and social wellbeing (P < 0.0001). Conclusions: Patients with advanced glaucoma report significant decline in functioning, their ability to interact in community, take care of self, and do leisure activities. Glaucoma imposes greater social burden on the elderly by impacting their sense of personal safety. Targeted visual and social rehabilitative programs are necessary to improve their wellbeing and independent functioning.

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Purpose: To evaluate the effects of a fish oil-containing regimen on the severity of retinopathy of prematurity (ROP) in preterm infants. Methods: In this retrospective, observational study, 82 preterm infants with documented retinal examinations were evaluated. Patients' demographic data, associated morbidities, the worst ROP zone, stage, and the presence of plus disease during the follow-up examinations, and the need for ROP treatment in the two groups were recorded and analyzed. Results: Forty-three infants were treated with INTRAlipid®, and 39 infants were treated with 20% SMOFlipid. There were no differences in gestational age, birth weight, and associated morbidities between the two groups. No differences were observed among the two groups in their need for treatment (P = 0.51), ROP zones (P = 0.62), and plus disease (P = 0.38). Although no difference was seen in ROP stages between the groups (P = 0.41), in subgroup analysis, Stage 3 (severe ROP) occurred significantly lower in the SMOFlipid group (P = 0.04) and Stage 0 occurred significantly higher in the SMOFlipid-treated infants (P = 0.05). Conclusions: This study showed no difference between the two groups regarding the need for the treatment. The lower prevalence of severe ROP in preterm infants receiving SMOFlipid emulsion was observed comparing to the INTRAlipid-treated infants.

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Purpose: To determine the prevalence of refractive errors and visual impairment and the correlation between personal characteristics, including age, sex, weight, and height, with different types of refractive errors in a population of university students in the south of Iran. Methods: In this cross-sectional study, a number of university majors were selected as clusters using multi-stage sampling in all universities located in Kazerun (27 clusters of 133 clusters). Then, proportional to size, a number of students in each major were randomly selected to participate in the study. Uncorrected and corrected visual acuity, non-cycloplegic objective refraction and subjective refraction were measured in all participants. Results: The prevalence and 95% confidence interval (CI) of presenting visual impairment and blindness was 2.19% (1.48–3.23) and 0.27% (0.12–0.62), respectively. Refractive errors comprised 75% of the causes of visual impairment. The prevalence (95% CI) of myopia [spherical equivalent (SE) ≤ –0.5 D], hyperopia (SE ≥ 0.5 D), and astigmatism (cylinder power < –0.5 D) was 42.71% (39.71–45.77), 3.75% (2.85–4.51), and 29.46% (27.50–31.50), respectively. Totally, 49.03% (46.39–51.68) of the participants had at least one type of refractive error. There was a positive association between weight and myopia (1.01; 95% CI: 1.01–1.02), anisometropia (1.03; 95% CI: 1.01–1.06), and refractive errors (1.01; 95% CI: 1.01–1.02). In comparison with the age group 18–19 years, the odds ratio (OR) of astigmatism in the age group 26–27 years was 1.64 (95% CI: 1.03–2.61), and the OR of anisometropia in the age group ≥ 30 years was 0.21 (95% CI: 0.04–0.98). Conclusions: The prevalence of refractive errors, especially myopia, is higher in university students than the general population. Since refractive errors constitute a major part of visual impairment, university students should receive special services for providing corrective lenses and glasses to reduce the burden of these disorders.

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Purpose: To assess the postoperative surgical outcomes and the changes in deviation in patients treated by supramaximal recession and resection (R&R) of rectus muscles to correct the large-angle exotropia and esotropia. Methods: This study was a prospective interventional case series, and patients with esotropia of ≥65 prism diopter (PD) or exotropia of ≥60 PD who had undergone supermaximal R&R in non-fixating eye with lower vision in unilateral strabismus or bilateral medial rectus (BMR) recession up to 8.5 mm for esotropia and bilateral lateral rectus (BLR) recession up to 12.5 mm for exotropia in bilateral strabismus were enrolled. Successful results were achieved if postoperation deviation was <10 PD for esotropia and <15 PD for exotropia during their final examinations. Results: A total of 131 cases (48 patients with esotropia and 83 patients with exotropia) were included. The mean ages of the patients with esotropia and exotropia were 16.83 ± 15.06 and 23.19 ± 11.29 years, respectively. The mean preoperative esodeviations for bilateral and unilateral surgeries were 69.5 ± 6.5 and 80.7 ± 10.3, respectively, and these values for bilateral and unilateral exodeviations surgeries were 67.3 ± 7.6 and 74.2 ± 12.1, respectively. The overall successful outcomes were achieved in 50% of the esotropic patients and 79.5% of the exotropic patients. At final follow-up examination, no patient had diplopia on lateral gazes. Conclusion: Based on our surgical results, it is possible to consider monocular recession-resection surgery in non-fixating eye (with poor vision) or BLR and BMR recession in both eyes as a viable option for surgical treatment of large angles deviations.

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Purpose: To report a case of chronic myelogenous leukemia (CML) treatment with imatinib mesylate in the remission phase who developed unilateral macular choroidal neovascularization (CNV). Methods: A 45-year-old male marketer with a 5-year history of CML treated with imatinib mesylate presented with 2 months history of progressive vision loss and metamorphopsia in the right eye. Results: Fundus examination of the right eye revealed grey-white elevated retinal lesion with indistinct borders in the macula and retinal telangiectasia in the temporal macula. Fluorescein angiography (FA) and optical coherence tomography angiography (OCTA) confirmed the presence of CNV in the right eye. After treatment with anti-vascular endothelial growth factor (anti-VEGF), macular CNV regressed significantly. Conclusion: Macular CNV must be kept in mind as a rare ophthalmic manifestation of patients with CML under treatment with imatinib even in the remission phase.

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Purpose: To evaluate the effect of preoperative 0.09% bromfenac ophthalmic solution for the reduction of intraoperative miosis and pain in patients who have undergone femtosecond laser-assisted cataract surgery. Methods: This prospective randomized clinical study included 65 patients with senile cataracts in the absence of significant ocular comorbidity. The patients received 0.09% bromfenac ophthalmic solution or control placebo twice a day for 3 days before surgery. Pupil diameter was measured at the initiation and finalization of femtosecond laser-assisted cataract surgery, and pain quantification was assessed by an analogous pain scale after one day of follow-up. Results: A total of 65 patients were randomly divided into two groups. Five patients were excluded due to defective coupling with the laser interface. Each of the 60 patients was randomized to receive preoperative topical treatment with either 0.09% bromfenac or 0.1% sodium hyaluronate. Baseline characteristics were similar between groups for age and gender. The mean change in horizontal and vertical pupil diameter from the preoperative to post-femtosecond laser measurements were significantly less in the bromfenac group than in the placebo group (0.43 ± 0.6 vs. 1.71 ± 0.9, P < 0.001 and 0.40 ± 0.6 vs. 1.78 ± 0.9, P < 0.001, respectively). Compared with untreated patients, the quantification of pain one day after the procedure was significantly lower in the 0.09% bromfenac group (46.7% with a score of 3 vs. 50% with a score of 1, P < 0.001, respectively). Conclusions: The maintenance of pupil dilation and the prevention of miosis were more effective in the 0.09% bromfenac group than in the control group. Likewise, the greater control of postoperative pain represented an additional significant benefit.

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Purpose: To evaluate the predictive and associated factors in determining the visual outcome in patients having central retinal vein occlusion (CRVO)-related macular edema (ME). Methods: The charts of the patients who were treated due to CRVO-related visual disturbance were reviewed. The optical coherence tomography (OCT) images of eyes were analyzed, and disorganization of retinal inner layers (DRILs), ellipsoid zone (EZ) and external limiting membrane (ELM) disruption length, hyper-reflectivity of retinal inner layer (HRIL) existence, baseline and final visual acuity (VA), subfoveal thickness (SFT), subretinal fluid (SRF), and injection numbers were noted. The regression and correlation analyses were applied. Results: Thirty eyes of thirty patients were included in the study. The mean follow-up time was 17.5 ± 11 (8–47) months. The mean baseline VA was 1.4 ± 0.7 (0.2–3.1) logMAR. A total of 87 intravitreal injections were applied for the treatment of ME during the follow-up. The initial mean central subfield thickness was 795 ± 264 (1470–398) μm. HRIL and SRF were observed in 16 and 23 eyes at the initial visit, respectively. The final mean VA was 1.2 ± 0.9 (0.1–3.1) logMAR. At the final visit, additional OCT parameters were evaluated. The mean DRIL length was 463 ± 324 μm. The mean disruption length of EZ and ELM was 367 ± 247 μm and 414 ± 327 μm, respectively. The final mean SFT was 290 ± 91 μm. SRF presence at the initial visit was found to be associated with elongated EZ and ELM disruption length at the final visit (P = 0.03 and P = 0.04, respectively). On linear regression analyses, none of the baseline features (SRF, SFT, and HRIL) except baseline poor best corrected visual acuity were found to be predictive in anticipating the final visual outcome (P = 0.04). On linear bivariate analysis, the final poor visual outcome was found to be affected by EZ disruption length of ≥500 μm at the last visit (P = 0.02). Conclusion: Baseline VA was the only predictive factor in anticipating the final visual outcome. At the final visit, extensive disruption length of EZ in the subfoveal area was associated with a poor visual outcome.

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Purpose: To explore the opinions of Canadian ophthalmologists on refractive and presbyopia-correcting surgeries. Methods: We distributed an online survey to the Canadian Ophthalmological Society members, covering laser refractive surgery (LRS), femtosecond laser-assisted cataract surgery (FLACS), lenticular refractive surgery (lenRS) that includes cataract refractive surgery (CRS) with premium intraocular lens (IOL) implantation, and presbyopia correction. Results: There were 68 (7.6%) total respondents. Most respondents would not consider LRS (62.5%) nor FLACS (73.9%) for themselves. Male sex and performance of LRS or FLACS was significantly associated with consideration of these procedures for self. Most respondents (59.3%) would consider lenRS for themselves. The top method of personal presbyopia correction was spectacles, chosen by 52.5%. Conclusions: When surveying the wide body of Canadian ophthalmologists, most respondents preferred spectacle correction of presbyopia and would consider lenRS, but not LRS or FLACS for themselves. Surgeons performing these procedures were more likely to consider them for self.

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Purpose: To investigate the presence of a probable genetic defect(s) that may cause primary congenital glaucoma (PCG) in a seven-year-old female patient. Methods: A seven-year-old female patient and her family received genetic counseling and underwent full clinical examinations by an expert ophthalmologist. The patient's genomic DNA was subjected to the targeted gene capture and next-generation sequencing (NGS) along with Sanger sequencing method. The 3D structure prediction and stereochemistry analysis were performed for both mutant and wild-type forms of the CYP1B1 protein. Results: The clinical examinations indicated that the diagnosis of PCG was correctly made. We identified a novel homozygous deletion in which a “C” nucleotide was deleted from the final exon of the Cytochrome P450 Family 1 Subfamily B Member 1 (CYP1B1) gene. The 3D molecular modeling of the CYP1B1 protein predicted significant structural changes could occur in this protein as a result of the mutation mentioned earlier. The stereochemistry analysis revealed mutant features of the protein, as well as significant misfolding and possible malfunctions in the mutant form of the CYP1B1 protein. Conclusions: This mutation might cause a frameshift in the translation process, leading to the malfunction of the CYP1B1 protein and development of glaucoma. This newly-identified mutation could be regarded as potential deletion mutation in genetic counseling and molecular examination for the detection of PCG disease in Iran.

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Purpose: To assess the achievement of anatomical integrity after primary tectonic sclerokeratoplasty procedure and outcome after subsequent secondary procedures to manage devastating corneoscleral infection threatening the structural integrity of the eyeball. Methods: This prospective interventional study comprised 60 patients with severe devastating corneoscleral pathology of infective origin with varying degrees of scleral involvement who underwent tectonic sclerokeratoplasty. They were grouped into three groups according to the involvement of scleral quadrants, i.e., Group A with only one quadrant, Group B with two quadrants, and Group C with more than two quadrants. The demographics, clinical features, microbiological status, postoperative complications, need for secondary procedures, and tectonic outcome in terms of anatomical success were analyzed in all three groups during follow-up between 2 and 5 years. Results: The donor graft size in Groups A, B, and C was 9.5–10.5, 11–12, and 12.5–14 mm, respectively. Globe integrity after primary procedure was noted in all patients of Group A, 76% of Group B, and 38% of Group C. Reinfection was observed in 19 cases of Groups B and C, from which 5 Group C patients were eviscerated and 14 underwent regrafting. Postoperative complications (suture related, rejection, graft failure, and secondary glaucoma) were encountered more frequently in Group C patients. Secondary procedures (cataract/posterior segment surgery, secondary intraocular lens, and trabeculectomy) were required more in Groups B and C. After regrafting, 7 eyes were salvaged and 7 (3 in Group B and 4 in Group C) resulted in phthisis bulbi. Thus, tectonic outcome was achieved in 80% of cases. Conclusions: Sclerokeratoplasty is an effective tectonic treatment for restoring the globe anatomy in severe corneoscleral infection. Outcome depends on involvement of scleral quadrants, graft size, and severity of disease. Subsequent regrafting procedures are required to overcome reinfection of the primary graft.

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Purpose: To assess the level of perceived satisfaction with the current level of ophthalmology training in Greece from the perspective of residents and to identify deficiencies in the training curriculum. Methods: This is a prospective, cross-sectional questionnaire-based study. An online, semi-structured questionnaire was designed to evaluate ophthalmology residents' extent of satisfaction with the quality of their postgraduate medical training. The survey was divided in two parts: demographics and evaluation of training. Resident ophthalmologists in all teaching hospitals in Greece were contacted and encouraged to complete it. Results: A response rate of 53.8% was achieved. Two out of three participants stated their disappointment with the quality of training they received and deemed the four-year residency training program as insufficient. Surgical training was also viewed as unsatisfactory by the majority of the respondents. An interest in subspecialty training, as well as a significant participation in research activities, was noted. Conclusions: Both training and overall satisfaction with working conditions must be improved to preserve the appeal of ophthalmology for young academics. A new, structured curriculum, reduction of unnecessary bureaucracy, and improved surgical training rank among the most essential priorities in order to improve postgraduate ophthalmology training.

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