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   Table of Contents - Current issue
Coverpage
July-September 2019
Volume 9 | Issue 3
Page Nos. 139-211

Online since Thursday, September 12, 2019

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EDITORIAL  

Dry eye disease revisited: What have we missed? p. 139
Chi-Chin Sun
DOI:10.4103/tjo.tjo_60_19  
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REVIEW ARTICLES Top

Update on the role of impression cytology in ocular surface disease p. 141
Zhang-Zhe Thia, Louis Tong
DOI:10.4103/tjo.tjo_57_19  
Understanding of the molecular pathology of ocular surface disease (OSD) is poor, and treatment is highly unsatisfactory. To facilitate treatment of OSD, a relatively noninvasive procedure, i.e. impression cytology (IC) has been shown to be useful. Recently, the technologies employed in research studies using IC in OSD have vastly improved, and standardized IC has even been used in clinical trials of dry eye. Here, this review aims to describe the advances of IC in the last 10 years, which serves as an update on the progress in this field since the last major review of IC. OSD that has been recently evaluated include meibomian gland dysfunction, Sjogren's syndrome, Steven–Johnson syndrome, and postmenopausal dry eye. The recent studies (4 longitudinal, 18 cross-sectional analyses) which utilized IC analyzed DNA, RNA, proteins, and ocular surface cells, including memory T-lymphocytes, dendritic cells (DCs), neutrophils, conjunctival epithelial cells, and goblet cells. These studies employed quantification of transcripts associated with inflammation, proteins involved in oxidative stress, enzymes such as matrix metalloproteinases, and cell surface proteins by flow cytometry, such as HLA-DR, cytokine and chemokine receptors, markers for T cell differentiation, and DC activation, in addition to the more traditional morphological evaluation of squamous metaplasia and staining for goblet cells. Some challenges in the clinical use of IC have also been described, including issues related to storage and normalization of data. In summary, advances in IC have permitted a more robust evaluation of the ocular surface and will facilitate progress in the understanding and treatment of OSD.
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Role of tear film biomarkers in the diagnosis and management of dry eye disease p. 150
Pak Yui Fong, Kendrick Co Shih, Pun Yuet Lam, Tommy Chung Yan Chan, Vishal Jhanji, Louis Tong
DOI:10.4103/tjo.tjo_56_19  
In recent years, there has been increasing scientific interest in the use of tear film biomarkers in the diagnosis and management of dry eye disease (DED), owing to their potential important roles in the pathogenesis of ocular surface damage, as well as the technical feasibility of tear sample collection techniques. An Entrez PubMed search was conducted on March 2, 2019, to include papers investigating the use of tear film biomarkers in DED, and the results were classified according to whether the DED is associated with systemic inflammatory disease or not and further classified within each section according to the molecular nature of the biomarker for further discussion. A total of 58 relevant articles were reviewed. Certain cytokines, including interleukin-6 (IL-6), tumor necrosis factor-alpha, IL-17, and IL-8, were found by a number of studies to consistently reflect disease severity well and had strong correlations with tear film metrics and tests for ocular surface damage in dry eye without systemic inflammatory disease. For dry eye with systemic inflammatory disease, IL-17, IL-8, and IL-1 receptor antagonists were shown to be consistently higher in affected eyes and correlated well with ocular surface disease severity in more than one type of inflammatory disease. With the advancement in technology and lowered costs in the future, tear film biomarker counts would allow better diagnosis and monitoring of DED, as well as facilitate personalized treatment strategies.
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Lamellar sclerokeratoplasty: Review of the literature and description of a special technique using fibrin glue and a giant hydrophilic contact lens p. 160
Eduardo Arenas, Alexandra Mieth
DOI:10.4103/tjo.tjo_54_19  
Lamellar sclerokeratoplasty is a surgical procedure described since 1979 by Lim in China and reported by different surgeons in the world. Our purpose is to report a modified technique in which not only the whole cornea with a scleral rim is utilized, but the importance of including the whole Schlemm's canal area is also insisted; therefore, a new aqueous humor drainage pathway can be restored. The technique is designed for cases in which not only the whole cornea is decompensated, but also have untreatable glaucoma. This procedure replaces the entire anterior segment with a clear donor cornea including the limbus and part of the trabecular meshwork. We present the results of visual acuity by the logMAR scale of 55 cases from 110 patients receiving this surgical technique. The results describe 39 cases that had visual improvement after more than 1 year of follow-up and 16 cases that did not improve in their visual acuity. Large-diameter sclerokeratoplasty is an alternative and therapeutic option to eliminate the entire corneal pathology, while obtaining structural and even optical results with a lower immunological reaction. It can be considered an option in cases that are not suitable for standard grafting procedures.
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ORIGINAL ARTICLES Top

Effects of flap diameter on dry eye parameters and corneal sensation after femtosecond laser-assisted LASIK p. 166
Yuan-Che Tai, Chi-Chin Sun
DOI:10.4103/tjo.tjo_59_19  
PURPOSE: Although femtosecond laser-assisted LASIK (laser-assisted in situ keratomileusis). provides a controllable flap size than a mechanical microkeratome, patients still experience dry eye symptoms after LASIK.The purpose of this study is to investigate the effects of different flap sizes on postoperative dry eye syndrome and corneal sensitivity. PATIENTS AND METHODS: This is a retrospective comparative study. Fifty-seven consecutive patients (113 eyes) who underwent myopic femtosecond laser-assisted LASIK treatment were recruited. Basic Schirmer's test value, tear breakup time (TBUT), corneal fluorescein staining scores, conjunctival rose bengal staining scores, and corneal sensitivity were measured before surgery, at postoperative 1, 3, and 6 months follow-up. RESULTS: When the eyes were grouped by flap diameter sizes (8.7 mm as the cutoff value), there were no significant differences in terms of corneal sensitivity and all dry eye parameters investigated at any time points between the large or small flap diameter groups. However, when the eyes were grouped by the ratio of flap diameter/horizontal corneal white-to-white distance (0.756 as the cutoff value), the larger ratio group showed decreased basic Schirmer's test (7.52 ± 4.43 mm) than the smaller group (12.15 ± 8.14) at 3 months (P = 0.006). Moreover, the group that had larger flap/corneal diameter ratio showed shorter TBUT (4.20 ± 1.73 s) than the smaller group (5.67 ± 1.90 s) at 6 months postoperatively (P = 0.011). CONCLUSIONS: LASIK-related dry eye syndrome was associated with flap/corneal diameter ratio, and surgeons should keep this effect in mind when customizing the cornea flap sizes for dry eye patients during LASIK.
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Comparison of topical cyclosporine alone and topical loteprednol with cyclosporine in moderate dry eye in Indian population: A prospective study Highly accessed article p. 173
Shaveta Singla, Lopamudra Sarkar, Mukesh Joshi
DOI:10.4103/tjo.tjo_15_18  
PURPOSE: The purpose of this study is to compare the efficacy of topical cyclosporine (Cs) 0.05% alone and topical Cs 0.05% with loteprednol 0.5% in patients with moderate dry eye. STUDY DESIGN: This was a comparative, prospective, interventional study. PATIENTS AND METHODS: A total of 140 patients diagnosed with moderate dry eyes were randomly divided into two groups. Group A patients received treatment with topical loteprednol 0.5% started as QID dosage for 2 weeks and tapered to BID dosage over the next 6 weeks, topical Cs 0.05% BID and artificial tears. Group B patients received treatment with topical Cs 0.05% BID and artificial tears. All patients were followed over a period of 6 months with ocular surface disease index (OSDI) questionnaire, tear film break up time (TBUT), corneal fluorescein, and lissamine green staining scores. RESULTS: There was a significant difference in the symptoms and signs of dry eye in the group receiving combination of loteprednol 0.5% and Cs 0.05% as compared to the group receiving Cs alone evident by greater reduction in OSDI score, corneal staining, and improvement in TBUT and Schirmer's test values over a follow-up of 6 months. CONCLUSION: Combination therapy with topical loteprednol and Cs is significantly better than topical Cs alone on alleviating symptoms and signs in moderate dry eye patients.
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Prevalence of microbial contamination in donor corneas p. 179
Nan-Ni Chen, Pei-Lun Wu, Hung-Chi Chen, Tsung-Yu Huang, Li-Ju Lai
DOI:10.4103/tjo.tjo_60_18  
BACKGROUND/PURPOSE: Postoperative infection is the most disastrous complication of penetrating keratoplasty (PK). Corneoscleral rim culture provided information regarding subsequent infections. Our aims were to identify the incidence of microbial contamination in donor corneas and to report the recovery of bacteria with two culture methods, i.e., conventional culture media after aerobic/anaerobic cotton swabs and blood culture media (Fastidious Antibiotic Neutralization [FAN]). MATERIALS AND METHODS: A total of 118 patients underwent PK. Corneoscleral rim cultures were performed using aerobic/anaerobic culture cotton swabs (Transystem™, COPAN, Italia) with subsequent convention media and blood culture media (FAN bottle, BD BACTEC™, USA). The results of the different methods were reported and analyzed. RESULTS: Microorganisms were recovered from 24 in total 118 cases (20.3%, n = 118), 14 from blood culture media (FAN) (11.8%, n = 118), 9 from conventional culture media after aerobic/anaerobic cotton swabs (7.63%, n = 118), and 2 from fungus culture (1.69%, n = 118). The most commonly identified pathogen was coagulase-negative Staphylococcus (CoNS) (n = 13, 54.2%), and more isolates of CoNS and staphylococcus aureus were recovered from blood culture media (FAN) than those from conventional culture media after aerobic/anaerobic cotton swabs (13 vs. 4,P= 0.05). Conversely, more nonfermentative Gram-negative bacilli were recovered from conventional culture media after aerobic/anaerobic cotton swabs. None of the 24 cases with positive corneoscleral rim cultures reported ocular infection for the recipients in at least 6 months' follow-up. CONCLUSION: The conventional culture media after aerobic/anaerobic cotton swabs and blood culture media (FAN) did not yield identical isolates of bacteria. The blood culture media (FAN) could further yield Gram-positive bacteria in addition to those recovered from convention media. It seemed adding gentamicin and streptomycin could achieve bacteriostatic effect instead of the bactericidal effect. The administration of postoperative antibiotic in the recipient was suggested.
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Factors associated with retinal screening among patients with diabetes in Taiwan Highly accessed article p. 185
Pai-Huei Peng, Sarah B Laditka, Huey-Shyan Lin, Hui-Chen Lin, Janice C Probst
DOI:10.4103/tjo.tjo_30_18  
PURPOSE: The purpose of this study is to explore the factors associated with having a diabetic retinopathy exam (DRE) during the past 2 years among patients with diabetes. METHODS: Patients visiting the eye clinic at Shin-Kong Memorial Hospital in Taipei were enrolled in this study from January to June 2009. A total of 313 patients participated in this study. Excluding patients with missing responses for more than three questions (38) yielded a final sample of 275 participants. Chi-square and Mann–Whitney U-tests were used for bivariate analysis. Multivariable logistic regression examined factors associated with having a DRE controlling for demographic and health factors. RESULTS: Although 83% of participants said that their physician suggested DRE, only 60% were screened during the past 2 years. In response to the question about why patients did not seek a DRE exam, 43.2% reported that they did not know having this exam was necessary. In adjusted results, receiving information about the relationship between diabetes and retinopathy from medical staff and believing that diabetes could damage the vision were associated with having a DRE in the past 2 years (both P < 0.05). CONCLUSIONS: Although most patients indicated that their physician suggested the need for eye care, a substantial percentage of patients with diabetes were not aware of the need for a regular DRE. Information about the relationship between diabetes and retinopathy and concerns about damage to vision were associated with greater likelihood of seeking a DRE. These factors should be considered to promote DR screening.
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CASE REPORTS Top

Clinical ocular manifestations of Taiwanese patients with mucopolysaccharidoses VI (Maroteaux–Lamy syndrome) p. 194
Hsu-Ying Lin, You-Hsin Huang, Shao-Yu Lei, Lee-Jen Chen, Shuan-Pei Lin
DOI:10.4103/tjo.tjo_85_17  
Mucopolysaccharidoses (MPS) is a group of lysosomal storage disorders that lead to accumulation of glycosaminoglycans (GAGs) in many tissues and organs, resulting in different clinical features. In this study, we conducted the manifestation changes of refractive error, corneal clouding, and intraocular pressure in two Taiwanese MPS VI patients with enzyme replacement therapy (ERT) initiated at the age of eight. In case 1, hyperopia was noted before and after ERT. Clinical observation showed no significant improvement in corneal clouding after ERT. In case 2, hyperopia was also noted initially before ERT and unable to be measured due to severe corneal opacity. Clinical observation showed no significant improvement in corneal clouding in after ERT, and the best-corrected visual acuity worsen and keratoplasty was needed in both eyes. Case 2 also had ocular hypertension and suspect MPS VI-related. However, due to severe corneal clouding, optic disc changes were hard to examine, and visual field was unable to be tested. Although some literature shows that ERT may be effective in preventing and/or clearing corneal stromal GAGs, accumulation and the timing of treatment initiation cloud be a clinical prognosis predictor; in this experience, no significant improvement of corneal clouding was observed in patients with MPS IV after ERT. Hyperopia and glaucoma were noted, and showed no changes after ERT. Severe corneal clouding can lead to difficulties in diagnosis and monitoring of hyperopia and glaucoma.
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Waardenburg syndrome with dry eyes: A rare association p. 198
Shrinkhal , Anupam Singh, Sanjeev Kumar Mittal, Ajai Agrawal, Rupal Verma, Preeti Yadav
DOI:10.4103/tjo.tjo_103_18  
Waardenburg syndrome (WS) is a rare congenital disorder primarily characterized by characteristic facial abnormalities as dystopia canthorum and synophrys; depigmentation of the hair, skin (premature graying of hair), and/or the iris of both eyes; and/or congenital deafness. Here, we report a rare case of WS with associated dry eyes. A 4-year-old female presented with blue eyes and no tear and nasal secretion production since birth. She was also deaf and dumb since birth. On examination, it was recognized as an atypical case of WS type 2 clinically, with several classical features such as white forelock, bilateral blue iris, hypopigmented fundus, smooth philtrum, bilateral profound hearing loss, and a rare association of bilateral dry eyes. The patient was given proper refractive correction, treatment of her dry eyes, and subjected to multidisciplinary approach as for the management of sensorineural hearing loss. It was a case of WS type 2 with a rare association of bilateral dry eyes.
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Bilateral corneal melting associated with topical diclofenac 0.1% after cataract surgery in a patient with Sjögren's syndrome p. 202
Pei-Ning Tu, Yu-Chih Hou
DOI:10.4103/tjo.tjo_3_19  
A 79-year-old female with Sjögren's syndrome (SS) underwent phacoemulsification and lens implantation in both eyes within 2 days. Postoperatively, topical diclofenac 0.1% and tobramycin 0.3% were applied. She presented 10 days later with photophobia, large central corneal melting, and visual acuity of counting finger in both eyes. Diclofenac was discontinued, and systemic doxycycline and steroids were administered. Amniotic membrane transplantation was performed in the left eye with topical steroid and autologous serum 20%. Corneal melting gradually healed in 3 weeks, but the centers of both corneas became thin and opaque. Hyperopic shift and irregular corneal surface were more significant in the right eye than in the left eye. Vision recovered to 0.05 and 0.1 in the right and left eyes, respectively. Topical nonsteroidal anti-inflammatory drugs should be used with caution in cataract surgery in patients with SS.
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Combined photorefractive keratectomy and cross-linking. Pushing the limits p. 206
Michael Tsatsos, Ioannis Athanasiadis, Cheryl MacGregor, Antonios Aristeidou, Marilita M Moschos, Nikolaos Ziakas
DOI:10.4103/tjo.tjo_7_19  
Correction of refractive error through laser-assisted means has soared in popularity in recent years, allowing it to become an increasingly routine surgical procedure. Technique refinement and adjustments resulted in laser-assisted refractive surgery to be combined with treatments such as collagen cross linking (CXL). This has broadened safety parameters and widened the treatment boundaries. Laser correction combined with CXL has been advocated in the treatment of high refractive errors as a safe option for full refractive correction while increasing corneal biomechanical stability. We present a complicated case where a young female patient with a preoperative best-corrected visual acuity (BCVA) of 20/20 in each eye was fully corrected by excimer laser followed by CXL. Factors potentially leading to inflammation, such as ocular surface disease, in addition to laser treatment and CXL, resulted in persistent epithelial defect followed by corneal melt and subsequent thinning. After the treatment, the patient relies on rigid gas-permeable contact lenses, achieving a BCVA of 20/25 and 20/23 in the right eye and left eye, respectively.
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LETTER TO THE EDITOR Top

Serpiginoid choroiditis, tuberculosis, and sarcoidosis p. 210
Beuy Joob, Viroj Wiwanitkit
DOI:10.4103/tjo.tjo_142_18  
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AUTHOR REPLY Top

Serpiginoid choroiditis, tuberculosis, and sarcoidosis p. 211
De-Kuang Hwang
DOI:10.4103/tjo.tjo_30_19  
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