Salivary exosomes have demonstrated vast therapeutic and diagnostic potential in numerous diseases. This study pioneers previously unexplored roles of SE in the context of corneal wound healing by utilizing primary corneal stromal cells from healthy (HCFs), type I diabetes mellitus (T1DMs), type II DM (T2DMs), and keratoconus (HKCs) subjects. Purified, healthy human SEs carrying tetraspanins CD9+, CD63+, and CD81+ were utilized. Scratch and cell migration assays were performed after 0, 6, 12, 24, and 48 h following SE stimulation (5 and 25 µg/mL). Significantly slower wound closure was observed at 6 and 12 h in HCFs with 5 μg/mL SE and T1DMs with 5 and 25 μg/mL SE. All wounds were closed by 24-hour, post-wounding. HKCs, T1DMs, and T2DMs with 25µg/mL SE exhibited a significant upregulation of cleaved vimentin compared to controls. Thrombospondin 1 was significantly upregulated in HCFs, HKCs, and T2DMs with 25 µg/mL SE. Lastly, HKCs, T1DMs, and T2DMs exhibited a significant downregulation of fibronectin with 25 μg/mL SE. Whether SEs can be utilized to clinical settings in restoring corneal defects is unknown. This is the first-ever study exploring the role of SEs in corneal wound healing. While the sample size was small, results are highly novel and provide a strong foundation for future studies.

Purpose: To compare the prediction accuracy of standard keratometry (K) and total keratometry (TK) for intraocular lens (IOL) power calculation in eyes undergoing combined cataract surgery and Descemet membrane endothelial keratoplasty (triple DMEK). Setting: Tertiary care academic referral center. Design: Retrospective case series. Methods: Review of 83 eyes (63 patients) that underwent triple DMEK between 2019 and 2021. Biometry measurements were obtained using a swept-source optical biometer (IOLMaster 700). 63 eyes were used for statistical analysis. Mean error, mean absolute error (MAE), SD, median absolute error, maximum absolute error, root mean squared prediction error, and the percentage of eyes within prediction errors of ±0.50 diopters (D) and ±1.00 D were calculated for 9 multivariate and third-generation formulas using K and TK values (Barrett Universal II, Yeo EVO 2.0, Cooke K6, Kane, Pearl-DGS, Haigis, Holladay 1, Hoffer Q, and SRK/T). Formulas were additionally tested by using the prediction for an IOL power 1 D below the IOL used (IOLup1D). Results: For all formulas, MAE was lower for K than for TK by an average of 0.21 D. The lowest MAE value observed was 0.67 D for “adjusted” SRK/T using K, and the highest MAE values observed were 1.24 D and 1.24 D for nonadjusted Hoffer Q and Haigis using TK, respectively. Overall, lower MAE values were observed for multivariate formulas and SRK/T. Conclusions: In triple DMEK eyes, the prediction accuracy of K was higher than that of TK. The most accurate formulas were SRK/T and multivariate formulas using K with the IOLup1D adjustment.

Collagen crosslinking (CXL) is a widely used treatment to halt the progression of keratoconus (KC). Unfortunately, a significant number of patients with progressive KC will not qualify for CXL, including those with corneas thinner than 400 µm. The present study aimed to investigate the molecular effects of CXL using in vitro models, mirroring the normal, as well as thinner corneal stroma seen in KCs. Primary human corneal stromal cells were isolated from healthy (HCFs) and keratoconus (HKCs) donors. Cells were cultured and stimulated with stable Vitamin C resulting in 3D self-assembled extracellular matrix (ECM), cell-embedded, constructs. CXL was performed on (a) thin ECM with CXL performed at week 2 and (b) normal ECM with CXL performed at week 4. Constructs without CXL served as controls. All constructs were processed for protein analysis. The results showed modulation of Wnt signaling, following CXL treatment, as measured by the protein levels of Wnt7b and Wnt10a, correlated to the expression of α-smooth muscle actin (SMA). Further, the expression of a recently identified KC biomarker candidate, prolactin-induced protein (PIP), was positively impacted by CXL in HKCs. CXL-driven upregulation of PGC-1 and the downregulation of SRC and Cyclin D1 in HKCs were also noted. Although the cellular/molecular impacts of CXL are largely understudied, our studies provide an approximation to the complex mechanisms of KC and CXL. Further studies are warranted to determine factors influencing CXL outcomes.

Purpose: To explore surgeons' perspectives and practice patterns in gray area surgical complications (GASCs) within cataract surgery. Setting: Tertiary care academic referral center. Design: Retrospective observational cross-sectional study. Methods: An anonymous, online survey consisting of 11 potential intraoperative GASC scenarios was developed and distributed to practicing and resident ophthalmologists in the U.S. Demographic data such as gender, experience, and practice settings were recorded. Using a Likert scale, respondents scaled their perception of likelihood that a GASC could lead to postoperative complications and their obligation toward patient disclosure and documentation in the operative report. Respondents also scaled their likelihood of agreement with a series of statements inserted to assess baseline anxiety levels and inherent perspectives regarding disclosure. Results: 389 responses were analyzed. Female surgeons were more likely than male surgeons to disclose GASCs to their patients and experience psychological anxiety regarding patient outcomes. Both early- and late-stage residents were more likely to believe that GASCs could lead to vision-limiting outcomes when compared with attending surgeons. Surgeons at academic centers were more likely than community-based surgeons to disclose GASCs in the operative report and experience psychological anxiety regarding patient outcomes. Conclusions: Significant differences based on gender, practice setting, and level of experience exist in disclosure and documentation of intraoperative GASCs. Additional studies are needed to further explore reasons for these differences, as reporting patterns may affect patient satisfaction, medicolegal risks, and postoperative surgeon-experienced anxiety.

Purpose. To describe a case of acute anterior uveitis (AAU) with HLA-B27 positivity following epithelium-off corneal cross-linking (CXL) in a patient with a previous intrastromal corneal ring segment. Observations. A 28-year-old male with keratoconus (KCN) developed ophthalmalgia, perilimbal injection, hypopyon, and decline in corrected distance visual acuity (CDVA) 3 days after CXL. A working diagnosis of inflammatory versus infectious AAU was made, and the patient was treated with topical tobramycin, polymyxin B/trimethoprim, prednisolone, and oral valacyclovir. Clinical appearance and CDVA improved, ultimately returning to baseline by two weeks postoperatively. Diagnostic laboratory workup revealed HLA-B27 positivity. Conclusions and Importance. A comprehensive laboratory workup is helpful to identify potential causative and associated systemic conditions when encountering AAU after CXL. Given the overlap in patient demographics for KCN and HLA-B27 positivity, clinicians should consider this entity in the differential diagnosis and treatment of such cases.