Journal of Current Ophthalmology
Volume:36 Issue: 1, Jan-Mar 2024

To explore the various aspects of adenoid cystic carcinoma of the lacrimal gland (LACC), including its clinical features, presentations, genetic factors, as well as current and potential future treatment options.

A thorough exploration of the literature was conducted by extensively searching the PubMed database. A total of 68 articles with a primary focus on adenoid cystic carcinoma were selected.

LACC is the most frequent malignant epithelial tumor of the lacrimal gland. It is characterized by the symptoms such as pain, progressive swelling of the eye, double vision, and bulging of the eye. Although LACC is a rare tumor, early detection and appropriate treatment are crucial due to its aggressive nature which includes high recurrence rate and a significant risk of mortality. The primary treatment options for LACC involve a wide range of surgical procedures, including orbitotomy, exenteration, and cranio‑orbital resection. Neoadjuvant intra‑arterial chemotherapy represents the paradigm shift in the treatment of LACC enhancing patient survival when compared to conventional treatments.

The existing literature emphasizes the importance of identifying prognostic factors that can guide treatment decisions and enhance the outcomes for patients with LACC.

To review the existing literature to evaluate the utility of insulin eye drops as a treatment for neurotrophic‑related epithelial defects.

A comprehensive literature search of Medline, Embase, and Web of Science and additional manual searches were conducted using relevant keywords. All articles published from January 2005 to January 2024 were examined. Studies on the use of topical insulin drops in neurotrophic epithelial defects were included.

A total of 16 articles were found relevant to be discussed in the review. All included patients had neurotrophic‑related epithelial defects ranging from 3.8 mm2 to 144 mm2. After treatment with topical insulin, most of the epithelial defects showed a complete epithelialization. Various concentrations and types of insulin were used. The studies also varied in the type of vehicle used in the preparation of insulin drops. Two randomized controlled trials demonstrated that topical insulin drops were more effective than conventional treatment with artificial tears or autologous serum. All included studies, except for two, reported the absence of local or systemic side effects.

Topical insulin is a promising and effective (adjuvant) treatment for neurotrophic keratopathy. It facilitates the healing of neurotrophic epithelial defects and offers many advantages over the current treatment options; insulin is widely available and it is relatively inexpensive. Topical insulin drops do not affect systemic blood glucose levels and are well tolerated. However, further investigation is needed.

To determine the short‑term outcomes of a modified Moorfields Safer Surgery System technique of trabeculectomy.

This is a prospective interventional study. Trabeculectomy was performed according to the author’s modification of Moorfields Safer Surgery System. This method allows titrating the opening pressure of trabeculectomy by varying the side cuts, varying the ostium size, and adjusting the tightness of the sutures. Forty‑four eyes of 43 patients were included. Main outcome measures include postoperative intraocular pressure (IOP), incidence of intra and postoperative complications, and success up to 6 months after surgery.

The mean preoperative and postoperative IOP at 6 months were 20.97 ± 7.93 mmHg and 12.69 ± 4.76 mmHg, respectively (n = 44). 70.5% of the patients had absolute success at 6 months, and the overall success was 88.6%. None of the patients had hypotony and there were no intraoperative complications noted. Forty‑two out of 44 eyes (95.5%) had diffuse formed blebs without leak on the 1st postoperative day. The most common postoperative complication (13.6%) was a conjunctival leak that was detected on fluorescein staining. In all these patients, the anterior chamber was deep, and the bleb well formed. These leaks were resolved with conservative measures. Many of these leaks would have been missed if not intentionally looked for. Excluding this complication, we had a complication rate of 9.1%.

The authors’ modification of the Moorfields Safer Surgery System technique may allow the surgeon to optimize aqueous flow through trabeculectomy while mitigating complications.

To evaluate and compare optical coherence tomography angiography (OCTA) retinal vasculature measurements in healthy, glaucoma suspect (GS), and glaucoma patients.

One hundred fourteen eyes with good quality OCTA pictures were included from 38 healthy, 38 GS, 38 and primary open‑angle glaucoma (POAG) participants. The information on retinal vasculature was summarized as a vessel density map and as vessel density (%), which is the fraction of the flowing vessel area over the total area examined. The superior, inferior, nasal, and temporal quadrants, as well as whole vessel density (wVD) and peripapillary vessel density (ppVD) data taken from the retinal nerve fiber layer, were studied. Global indices of the visual field were correlated with vessel density measurement.

Mean vessel density was significantly lower in POAG eyes compared with GSs and healthy eyes (wVD) 45.34% ± 6.64%, 50.06% ± 1.97% and 53.06% ± 2.12%, respectively (P < 0.001), and ppVD 47.42% ± 7.73%, 47.42% ± 7.73% and 56.074% ± 2.71%, respectively (P < 0.001). A linear relationship between vessel density (wVD and ppVD) and global indices of the visual field (mean deviation [MD] and pattern standard deviation [PSD]) shows a significant (P < 0.001) relation. R2 is 0.35, 0.36, 0.36, and 0.33 for MD and wVD, PSD and wVD, PSD and ppVD, and MD and ppVD, respectively.

For distinguishing between healthy and glaucoma eyes, OCTA vessel density demonstrated near similar diagnostic accuracy to visual field tests. These findings imply that OCTA measurements reflect damage to tissues important in the pathogenesis of POAG.

To compare the corneal epithelial thickness along the flat and steep meridians of corneas with low and high toricity.

This was a prospective observational comparative study on healthy subjects with normal corneas seeking preoperative evaluation for refractive surgery at a university‑based hospital. Subjects with up to 2 diopters (D) of corneal with‑the‑rule astigmatism were defined as low corneal toricity (CT), whereas cylinder > two‑dimensional was considered as high CT. The anterior segment optical coherence tomography was conducted to measure the epithelial thickness along the principle meridians of CT over a diameter of 9 mm. At the eye level, outcome variables (corneal and epithelial thicknesses in low‑ and high‑astigmatism groups) were assessed using generalized estimating equation models.

Included were 98 eyes (49 subjects): 46 eyes (23 subjects) with low CT and 52 eyes (26 subjects) with high CT. Two groups were similar with respect to the age (P = 0.82), sex (P = 0.49), and spherical equivalent (P = 0.11). Although the corneal thickness at steep and flat meridians was not different between two groups, high‑CT group had significantly thinner epithelium at inferior 2.5–3.5 and 3.5–4.5 mm zones (P = 0.01 and 0.04) as well as superior 2.5–3.5 mm zone (P = 0.03) along the steep meridian. Two groups were similar with respect to epithelial thickness of flat meridian (all P > 0.05).

The epithelium of steep meridian was thinner in the high‑CT group compared to the low‑CT group.

To evaluate the prevalence of dry eye, meibomian gland dysfunction (MGD), and conjunctivochalasis in patients with obstructive sleep apnea (OSA).

We included 37 patients diagnosed with OSA according to polysomnography. The control group comprised 31 subjects. The study participants underwent a complete ophthalmic examination and ocular surface assessment. Meibography was done using infrared imaging. Furthermore, tear meniscus height was measured using anterior segment optical coherence tomography.

The mean age of the OSA and control groups were 50.3 ± 9.0 and 50.3 ± 8.0, respectively (P = 0.77). The mean scale for meibomian gland expression, meibomian gland plugging, and lid margin telangiectasia was similar in both groups. The meiboscores of the upper and lower eyelids were similar in both groups (upper meiboscores of 0.67 ± 0.48 and 0.37 ± 0.49 in OSA and control group, P = 0.180 and lower meiboscores of were 0.47 ± 0.57 and 0.22 ± 0.42 in OSA and control group, P = 0.179). The mean tear break-up time (TBUT) was significantly lower in the OSA group (8.17 ± 3.70 compared to 11.47 ± 4.52, P < 0.001). Upper and lower tear meniscus height were 186.14 ± 40.11 μm and 199.59 ± 37.22 μm and 237.25 ± 82.86 μm and 218.59 ± 68.8 μm in OSA and control group, respectively (P = 0.221, P = 0.166). The mean conjunctivochalasis grading score was 0.92 ± 0.72 and 0.81 ± 0.65 in the OSA and control groups, respectively (P = 0.143).

Despite decreased TBUT in patients with OSA, other dry eye parameters are not altered in these patients. Moreover, the frequency of MGD and conjunctivochalasis is not higher in OSA patients.

To develop an artificial intelligence (AI) approach for differentiating between normal cornea, subclinical, and keratoconus (KC) using tomographic maps from Pentacam (Oculus) and corneal biomechanics from Corvis ST (Oculus).

A total of 1,668 tomographic (769 patients) and 611 biomechanical (307 patients) images from the Chula Refractive Surgery Center, King Chulalongkorn Memorial Hospital were included. The sample size was divided into the Pentacam and combined Pentacam‑Corvis groups. Different convolutional neural network approaches were used to enhance the KC and subclinical KC detection performance.

AI model 1, which obtained refractive maps from Pentacam, achieved an area under the receiver operating characteristic curve (AUC) of 0.938 and accuracy of 0.947 (sensitivity, 90.8% and specificity, 96.9%). AI model 2, which added dynamic corneal response and the Vinciguerra screening report from Corvis ST to AI Model 1, achieved an AUC of 0.985 and accuracy of 0.956 (sensitivity, 93.0% and specificity, 94.3%). AI model 3, which added the corneal biomechanical index to AI Model 2, reached an AUC of 0.991 and accuracy of 0.956 (sensitivity, 93.0% and specificity, 94.3%).

Our study showed that AI models using either anterior corneal curvature alone or combined with corneal biomechanics could help classify normal and keratoconic corneas, which would make diagnosis more accurate and would be helpful in decision‑making for the treatment.

To evaluate the repeatability of a pyramidal wavefront-based refraction (WFR) measurement and its agreement with dry autorefraction (DR), cycloplegic autorefraction (CR), and subjective refraction (SR) in myopic refractive surgery candidates.

One hundred eighty‑nine eyes from 189 participants were evaluated. PERAMIS aberrometry (PERAMIS; SCHWIND eye‑tech‑solutions, Kleinostheim, Germany), DR, and CR, as well as SR, were completed for all candidates. The repeatability of PERAMIS measurements was assessed, and the Bland–Altman plots were used to test the agreement between different methods.

Repeatability of the PERAMIS aberrometer was very high in the measurement of all refractive elements (Sphere, cylinder, spherical equivalent [M], J0, and J45) (interclass correlation coefficient >0.980 for all). A significant myopic shift was found with WFR compared to CR (0.45 diopter [D]) and SR (0.28 D) (P < 0.05). For the M component, there was a significant difference between WFR and CR (P < 0.05). J0 component measured with WFR was significantly different from SR and CR (P < 0.05). For the J45 variable, all three refraction methods were comparable (all, P > 0.05). In M > 5.00 D, a difference of 0.79 D (limit of agreement: −3.50–1.90) was found between WFR and CR.

In lower degrees of myopia, WFR was in good agreement with the manifest autorefraction. WFR, CR, and SR techniques were comparable in measuring astigmatism, especially in oblique astigmatism.

To evaluate the efficacy of eplerenone in central serous chorioretinopathy (CSCR) patients in a clinical trial design.

In this double‑blind clinical trial, naive acute CSCR patients were divided into two groups: treatment with eplerenone 25 mg daily in the 1st week followed by 50 mg for the next 3 weeks and placebo group. Best‑corrected visual acuity (BCVA), central macular thickness (CMT), macular volume (MV), and choroidal thickness (CT) were measured before and after 1 month of the intervention using the optical coherence tomography technique.

Thirty‑one CSCR (male: 23, female: 8) and 25 CSCR patients (male: 18, female: 7) with the mean age of 35.65 ± 5.94 and 37.08 ± 6.41 years were recruited and divided randomly into treatment and placebo groups, respectively. BCVA improved significantly in the treatment group (from 0.28 ± 0.26 to 0.11 ± 0.14, P = 0.002) compared with the placebo group (from 0.31 ± 0.26 to 0.21 ± 0.14, P = 0.052). Although CT, CMT, and MV improved significantly in each group, there were no significant differences between the groups.

In this study, we found favorable short‑term clinical effects of eplerenone in acute CSCR patients, showing the pivotal role of mineralocorticoid receptors in the retina.

To investigate the correlation between choroidal biomarkers using enhanced depth imaging optical coherence tomography (EDI‑OCT) and indocyanine green angiography (ICGA) scoring for monitoring the activity of Vogt–Koyanagi–Harada (VKH).

Patients who were not in the acute phase of VKH were recruited. Simultaneous EDI‑OCT and ICGA were captured in seven patients only at baseline, in six patients at the 3‑month follow‑up, and in two patients at both the 6‑ and 9‑month follow‑ups. Subfoveal choroidal thickness (SFCT), subfoveal choroidal area (SFCA), and choroidal vascular index (CVI) were measured on EDI‑OCT using FIJI software and a denoising system. ICGA scoring was performed.

Fifteen subjects with the median of 4‑month follow‑up were recruited. Forty‑eight pairs of EDI‑OCT and ICGA were investigated. In univariate analysis, ICGA scores were positively associated with SFCT, and SFCA, but negatively with CVI. The strength of correlation between ICGA scores and SFCT was strong (correlation coefficient: 0.91). In multivariate analysis, only SFCT remained significant (B: 2.4, 95% confidence interval: 1.9–3.0; P < 0.001).

SFCT can be an acceptable representative of the subclinical inflammatory activity of VKH. As an alternative to ICGA, SFCT functions better than SFCA and CVI.

To study the outcomes and complications of Nd:YAG laser capsulotomy in patients with uveitis.

This study retrospectively evaluated outcomes of Nd:YAG laser capsulotomy in 260 eyes of 260 patients with uveitis. The main indications for performing capsulotomy were a visually significant posterior capsule opacification (PCO) and inability to visualize the posterior segment. The presence of 5 or <5 cells per high‑power field in the anterior chamber for a minimum period of 3 months was a prerequisite for capsulotomy.

The mean age of patients was 52.8 ± 11.3 (range, 38–75 years). The incidence of PCO in the study was 22.4%. The mean follow‑up was 21.5 ± 11.3 months postcapsulotomy. The mean best‑corrected visual acuity (BCVA) improved in 161 (62%) eyes after capsulotomy. The BCVA remained stable in 50 (19.3%) eyes due to preexisting ocular pathology involving the macular area. There was worsening of BCVA in 49 (18.8%) eyes. The main causes of worsening of BCVA were sustained intraocular pressure (IOP) elevation (n = 13%), cystoid macular edema (CME) (n = 8.5%), and retinal detachment (RD) (n = 2.7%), respectively. Ninety‑one percent (n = 20) of patients with CME had exaggerated postlaser inflammation and recurrent uveitis. The presence of posterior vitreous detachment (PVD) and higher laser energy levels were significant risk factors for RD.

Nd:YAG laser capsulotomy in patients with uveitis may be associated with complications. Inflammation and IOP should be well controlled before initiating laser capsulotomy. Capsulotomy should be performed with caution in patients with preexisting PVD.

To evaluate the answers to multiple‑choice questions about retina and vitreous diseases and treatment modalities of Chat Generative Pre‑Trained Transformer (ChatGPT), Bard, and Bing artificial intelligence chatbots, examining the level of knowledge about these subjects, and investigating the existence of their superiority over each other.

Forty‑six questions related to retinal and vitreous diseases and treatment modalities were asked to ChatGPT, Bing, and Bard chatbots.

The Bing artificial intelligence chatbot correctly answered 76.1% of the questions. ChatGPT and Bard artificial intelligence chatbots correctly answered 60.9% of the questions. No statistically significant difference was observed between the rates of correct and incorrect answers to the questions on the three artificial intelligence chatbots (P = 0.206).

Artificial intelligence chatbots can be used to access accurate information about retinal and vitreous diseases and treatment modalities. However, the information obtained may not always be correct, and care should be taken about its use and results.

To determine myopic progression, axial length elongation, best‑corrected visual acuity (BCVA), pupil dilation, and accommodation amplitude following 24 months of Atropine 0.01% usage among progressive myopic patients.

Fifty‑one progressive myopic patients (age range, 3.5–17 years) were included in the present study. Fifteen patients were excluded due to loss to follow‑up (eight patients) and Atropine complications (seven patients) and 36 patients continued therapy. Myopic progression, axial length, far and near BCVA, pupil diameter, and accommodation amplitude were measured at baseline examination and repeated every 6 months up to 2 years. All patients were recommended to instill one drop of Atropine 0.01% in each eye every night. Absolute success of therapy was defined as myopic progression ≤0.50 diopter (D) and axial length growth ≤0.2 mm per year.

Mean myopic progression was 0.16 and 1.28 D and mean axial length change was 0.05 and 0.69 mm at months 12 and 24, respectively. Pupil dilation was 1.26 and 1.84 mm and accommodation reduction was 3.38 and 3.37 D at the same follow‑ups, while BCVA was not changed. Absolute success rate for myopic progression control was 56.8% at 12 months and 70.8% at 24 months follow‑up. In addition, the success rate in respect to axial length changes was 44.4% and 58.3% at the same time points.

Atropine 0.01% can slow myopic progression and axial length elongation at least in 50% of myopic cases at 12‑ and 24‑month follow‑up with no significant complications. Therefore, Atropine therapy is recommended in cases of progressive myopia in children and teenagers.

To analyze the correlation between orbital computed tomography (CT) scan measurements including the fracture area (FA), the fracture location, the soft‑tissue herniation volume (HV), the fractured orbital volume ratio (OVR) to the normal orbit, and the clinical enophthalmos in acute isolated orbital floor fractures.

We enrolled 100 patients with acute isolated unilateral orbital floor fractures from May 2017 to January 2021. Based on the CT scan findings, we measured the FA, HV, OVR, and fracture site. We assessed enophthalmos using both clinical (CE) and radiographic (RE) measurements. Additionally, we investigated the correlation between CE and the measured parameters, along with the relationship between the pattern of diplopia and the fracture site.

We identified enophthalmos in 81% and diplopia in 78% of the patients with an acute blowout orbital floor fracture. CE was moderately correlated with the FA (R2 = 0.4341, P < 0.001). CE was weakly correlated with the HV (R2 = 0.2861, P = 0.04). Anterior fractures caused diplopia in both vertical gazes, but posterior fractures were mostly associated with diplopia in the up gaze. OVR was strongly associated with RE (R2 = 0.663, P < 0.0001) and moderately associated with CE (R2 = 0.4378, P < 0.0001). The univariate regression analysis also showed that OVR could significantly predict CE and RE.

OVR surpasses other CT scan measurements such as FA and HV in the prediction of clinical enophthalmos. Thus, OVR could be utilized to estimate clinical enophthalmos at the time of presentation, especially when the acute clinical setting prohibits the proper clinical evaluation.

To highlight the rarity of the endothelial rejection line, also known as the Khodadoust line, as a manifestation following Descemet’s stripping automated endothelial keratoplasty (DSAEK). The objective is to present a meticulously detailed case, including imaging and anterior optical coherence tomography (OCT), to enhance understanding and recognition of this phenomenon.

A detailed case presentation involving a 50‑year‑old male, 3 years post‑DSAEK transplantation for endothelial damage resulting from intraocular surgeries. The patient urgently sought consultation due to vision loss while under daily fluorometholone use. Clinical examination revealed acute graft rejection characterized by corneal edema, anterior chamber reaction, and the presence of keratic precipitates forming a Khodadoust line. The management approach included the initiation of a tapered dexamethasone regimen.

The identified acute graft rejection, marked by the presence of a Khodadoust line, demonstrated favorable responsiveness to the initiated tapered dexamethasone regimen. Corneal OCT and imaging played crucial roles in providing detailed insights into the manifestation.

While the endothelial rejection line (Khodadoust line) is a rare occurrence following DSAEK, this case underscores its potential association with graft rejection. The successful management outlined in this report suggests the importance of prompt recognition and appropriate anti‑inflammatory intervention in such cases to achieve positive outcomes.

To present a case of bilateral neurotrophic keratopathy (NK) following an inactivated coronavirus disease 2019 (COVID‑19) vaccine administration.

Case report.

A 46‑year‑old female patient was referred to our cornea department with unhealing corneal epithelial defects in both eyes. The patient’s complaints, including ocular redness, sensitivity to light and blurred vision, started 1 week after the second dose of CoronaVac® vaccine and continued to increase for 2 months. Ophthalmological examination revealed mild ocular redness, epithelial defects in the central cornea, and decreased corneal sensitivity in both eyes. No pathology that could cause NK was detected in the patient’s anamnesis and tests. Treatment including bandage contact lens application, autologous serum eye drops, preservative‑free artificial tears, and oral doxycycline resulted in closure of the epithelial defect on the 10th day, and on the 2‑month follow‑up visit, it was observed that corneal sensitivity had increased.

In the presented case, it is thought that bilateral NK may be associated with the vaccine due to the chronological relationship between the vaccine administration and the lack of any other explanatory etiology. A cure was achieved in a short time with appropriate treatment, and the increase in corneal sensitivity over time indicates that the corneal neuropathy was reversible. Nowadays, with the worldwide administration of COVID‑19 vaccines, ophthalmologists should keep in mind that, although rare, NK manifestation may still be encountered after vaccination.

To describe the first reported instance of an acute chorioretinal inflammatory response to cabozantinib.

Case report.

A 54‑year‑old Asian male presented with blurred vision 2 weeks following the commencement of cabozantinib for metastatic renal cell carcinoma. Ophthalmic examination revealed bilateral exudative retinal detachments and choroiditis in a pattern similar to Vogt–Koyanagi–Harada disease. Further investigations revealed latent tuberculosis (TB), and management of this ocular adverse event was with cabozantinib cessation, high‑dose oral prednisone, single‑agent anti‑TB therapy, and methotrexate. Return of visual function and ocular anatomy occurred within 1 month.

Modern pharmacotherapy for metastatic cancer may increase survival, but a range of ocular and systemic adverse events are frequently seen. Screening and early intervention can mitigate adverse events and treatment burden, while maximizing benefits for this disadvantaged patient group.

To report two cases of diffuse unilateral subacute neuroretinitis (DUSN) from northern Iran and to present the sequential imaging.

Two patients with large subretinal nematodes were evaluated and managed in our clinic. Serial fundus photography and optical coherence tomography (OCT) imaging were used to document the course of the disease. Laser photocoagulation was administered to manage the patients.

The migration of the nematodes from subinternal limiting membrane space to subretinal space was documented in one case, coinciding with the onset of inflammatory and destructive processes. Both patients were successfully managed using laser photocoagulation alone. Follow-up examinations revealed partial recovery of the outer retinal layers and improvement in visual acuity. Nevertheless, some persistent atrophy in the retinal nerve fiber layer and ellipsoid layer was noted in the final examination.

We presented two cases of DUSN from northern Iran, with OCT documentation of transretinal migration in one case. Photocoagulation laser alone is an effective treatment modality in the early stage. The suboptimal final visual acuity appears to be linked to both inner and outer retinal layers’ damage.