PURPOSE: To compare immediate sequential bilateral corneal cross-linking (CXL), wherein both eyes are treated on the same day, to delayed sequential bilateral CXL, where each eye is treated on different days for bilateral progressive keratoconus. METHODS: This was a retrospective case note review of all patients who underwent sequential CXL or delayed CXL for keratoconus at Royal Liverpool University Hospital, United Kingdom. Parameters assessed were the change in maximum keratometry and minimum central corneal thickness on corneal tomography scan, corrected distance visual acuity, and cost estimates of treatment. RESULTS: A total of 38 patients (31 men and 7 women) with keratoconus with a mean age of 25.3 ± 7.0 years were included. Twenty patients received sequential CXL and 18 received delayed CXL treatment. In both the sequential CXL and delayed CXL groups, the treated eye(s) showed no evidence of progression after the corneal CXL treatment at last follow-up visit after 358 ± 158 days for sequential CXL and 451 ± 205 days for delayed CXL. There were no complications from the treatment in either group. In the delayed CXL group, the mean time interval between the two CXL procedures was 146 ± 129 days. Five of 18 patients (27%) showed progression of keratoconus in their second eye during the waiting time. Economical evaluation showed that four visits were saved for each sequential CXL treatment compared to delayed CXL. CONCLUSIONS: Delayed CXL carries a risk of progression in the second eye and is associated with a higher economic burden. [ J Refract Surg . 2020;36(8):552–556.]

Purpose: To assess the variability of osmolarity measured by the point-of-care TearLab system in healthy eyes. Methods: A systematic review was performed by searching MEDLINE, Scopus, and the Web of Science Databases until November 2016 and checking reference lists of included articles and reviews. The requirements for inclusion were the availability of TearLab results in healthy subjects and a minimum study sample of 20 eyes. Two reviewers assessed articles against the inclusion criteria, extracted relevant data, and examined the methodological quality. We computed the weighted mean osmolarity using the study size as the weighting factor and calculated the rate of subjects with osmolarity values >308 mOsm/L, the Dry Eye Workshop Report 2017 (DEWS) cut-off value for dry eye disease (DED). We repeated the analysis after excluding reports with a possible conflict of interest or missing description of subject selection. Results: Searches retrieved 105 nonduplicate articles, and we included 33 studies investigating 1362 eyes of healthy participants who were asymptomatic and showed no clinical signs of DED. Sixty-three percent were female, and mean age was 37.3 years (range: 21.5–69.0 yr). Weighted mean osmolarity was 298 mOsm/L (95% confidence interval, 282–321 mOsm/L). The result of the subgroup analysis was similar. Overall, 386 of 1362 eyes (28.3%) fulfilled the DEWS's definition of DED (>308 mOsm/L). Conclusions: There is a high variability of osmolarity measurements with the TearLab system. A substantial number of healthy subjects fulfill the DEWS's definition of DED. We propose interpreting the TearLab osmolarity results cautiously and in the context of other established methods.

Purpose: The prevalence of keratoconus in the general population is reported to be up to 1 of 84. Over the past 2 decades, diagnosis and management evolved rapidly, but keratoconus screening in clinical practice is still challenging and asks for improving the accuracy of keratoconus detection. Deep learning (DL) offers considerable promise for improving the accuracy and speed of medical imaging interpretation. We establish an inventory of studies conducted with DL algorithms that have attempted to diagnose keratoconus. Methods: This systematic review was conducted according to the recommendations of the PRISMA statement. We searched (Pre-)MEDLINE, Embase, Science Citation Index, Conference Proceedings Citation Index, arXiv document server, and Google Scholar from inception to February 18, 2022. We included studies that evaluated the performance of DL algorithms in the diagnosis of keratoconus. The main outcome was diagnostic performance measured as sensitivity and specificity, and the methodological quality of the included studies was assessed using QUADAS-2. Results: Searches retrieved 4100 nonduplicate records, and we included 19 studies in the qualitative synthesis and 10 studies in the exploratory meta-analysis. The overall study quality was limited because of poor reporting of patient selection and the use of inadequate reference standards. We found a pooled sensitivity of 97.5% (95% confidence interval, 93.6%–99.0%) and a pooled specificity of 97.2% (95% confidence interval, 85.7%–99.5%) for topography images as input. Conclusions: Our systematic review found that the overall diagnostic performance of DL models to detect keratoconus was good, but the methodological quality of included studies was modest.

Background: The optical quality in progressive keratoconus deteriorates due to ectasia and distortion of the corneal shape and optics. While corneal cross-linking (CXL) aims at stopping disease progression, “CXL-Plus” combines CXL with excimer laser ablation to improve visual function. Central Corneal Regularization (CCR) represents a therapeutic excimer laser modality specifically designed to smoothen the ectatic corneal shape and to reduce higher order aberrations (HOA). We set out to compare CXL-Plus, consisting of CXL combined with CCR, with CXL by itself for patients with progressive keratoconus.Methods: Retrospective 2-year matched group analysis of patients who either underwent CXL-Plus (n = 28) or CXL as a sole procedure (n = 28) for progressive keratoconus. Main outcome parameters were HOA, visual function and tomographic results 12 and 24 months postoperatively.Results: After 12 months, the total HOA root mean square wavefront error was reduced from 0.79 ± 0.30 to 0.40 ± 0.19 μm (CXL-Plus;p < 0.0001) and changed from 0.71 ± 0.28 to 0.73 ± 0.36 μm (CXL;p = 0.814). Uncorrected distance visual acuity improved from 0.70 ± 0.35 to 0.36 ± 0.29 logMAR (CXL-Plus;p = 0.0002) and from 0.65 ± 0.39 to 0.46 ± 0.37 logMAR (CXL;p = 0.067), translating to gains of three or more lines in 50% (CXL-Plus) and 36% (CXL) of patients. The steepest keratometry value (Kmax) regressed by 5.84 D (CXL-Plus;p < 0.0001) and 0.66 D (CXL;p = 0.752). For none of the investigated parameters a statistically significant change could be shown between 12 and 24 months.Conclusions: CXL-Plus in the form of a CCR reduces HOA and Kmax more effectively than CXL as a sole procedure.

Background This review reports the epidemiology, laboratory results, treatment regimens and costs of fungal keratitis at a tertiary referral center in Lucerne, Switzerland. Patients and Methods Culture-proven fungal infections between January 2010 and December 2015 were reviewed retrospectively. Results Seventeen patients with a mean age of 52 years were identified. Contact lens wear was the most important risk factor (n = 11) (65 % of all cases), with filamentous fungi being identified as the most common fungus type (n = 10) (91 % of all cases of contact lens-associated fungal keratitis). All non-contact lens-associated fungal infections (n = 6) (35 % of all cases) were related to Candida spp. Six patients (35 %) were treated on an outpatient basis; 11 cases (65 %) required hospitalisation. Systemic voriconazole was the treatment regimen prescribed most often (n = 12) (71 %), followed by topical natamycin 5 % (n = 11) (65 %). Corneal crosslinking and penetrating keratoplasty were required in 4 cases each (24 %). One case ended up in enucleation (6 %). Average costs per case were EUR 15 952 for hospitalised patients if surgical intervention was required, and EUR 7415 if no intervention was performed. Average costs for outpatients were EUR 7079. In a majority of cases, visual acuity could be improved (n = 9) (53 %) or preserved (n = 2) (12 %). Conclusion Despite the relatively low incidence of culture-proven keratitis (17 cases in 6 years), a clear pattern with regard to risk factors and fungus species was noted. In the absence of a gold standard for the treatment of fungal keratitis, the combination of systemic voriconazole and topical natamycin seems to be one of the most commonly used antifungal treatment regimens. The costs of outpatient versus inpatient non-surgical treatment were approximately the same. Hintergrund Der vorliegende Review gibt einen Überblick über die Epidemiologie, Laborresultate, Behandlungsschemen und Kosten der Pilzkeratitiden, die an einem tertiären Hornhautzentrum in Luzern, Schweiz, behandelt worden sind. Patienten und Methoden Retrospektiv wurden alle kulturpositiven, antifungal behandelten Pilzkeratitiden zwischen Januar 2010 und Dezember 2015 analysiert. Resultate Siebzehn Patienten mit mittlerem Alter von 52 Jahren wurden eingeschlossen. Kontaktlinsen zeigten sich als häufigster Risikofaktor (n = 11, 65 % aller Fälle), davon waren 10 Fälle mit filamentösen Pilzen assoziiert (91 % aller Pilzinfekte bei Kontaktlinsenträgern). Bei allen nicht kontaktlinsenassoziierten Keratitiden (n = 6, 35 % aller Fälle) wurden Candida spp. nachgewiesen. Sechs Patienten (35 %) wurden ambulant, 11 Patienten (65 %) stationär behandelt. Voriconazol systemisch war die am häufigsten verschriebene Therapie (n = 12, 71 %), gefolgt von topischem Natamycin 5 % (n = 11, 65 %). Ein korneales Crosslinking respektive eine perforierende Keratoplastik erfolgte in je 4 Fällen (je 24 %), eine Enukleation in 1 Fall (6 %). Die durchschnittlichen Behandlungskosten für stationäre Patienten betrugen EUR 15 952 mit respektive EUR 7415 ohne chirurgische Intervention, bei den ambulant behandelten Patienten EUR 7079. In den meisten Fällen konnte eine Verbesserung (n = 9, 53 %) oder ein Erhalt des Visus (n = 2, 12 %) erreicht werden. Schlussfolgerung Trotz der relativ tiefen Inzidenz (17 Fälle in 6 Jahren) zeigte sich eine klare Zuordnung in Bezug auf Risikofaktoren und nachgewiesene Pilzspezies. Bei Fehlen eines Therapie-Goldstandards scheint die Kombination aus systemischem Voriconazol und topischem Natamycin eine der am häufigsten verwendeten Behandlungsoptionen darzustellen. Die Kosten einer ambulanten und einer stationären, nicht operativen Behandlung sind annähernd gleich.