Applications of Anterior Segment Optical Coherence Tomography in Cornea and Ocular Surface Diseases

Evaluation of anatomical and functional success in canalicular laceration repair using anterior segment optical coherence tomography and dacryoscintigraphy

PURPOSE

To assess the anatomical and functional outcomes in patients who underwent surgery for canalicular laceration and did not experience significant epiphora, and to compare these outcomes with contralateral uninjured eye.

METHOD

Dacryoscintigraphy, anterior segment optical coherence tomography (OCT), MUNK scores, and a satisfaction questionnaire were administered to 24 patients who had canalicular laceration repair without significant epiphora and had a minimum of 6 months of follow-up. Tear meniscus height (TMH), depth (TMD), and area (TMA) were measured using anterior segment OCT and compared with the values in the uninjured eye.

RESULTS

Sixteen patients (67 %) had lower, 7 (29 %) had upper canaliculus, and one (4 %) had lacerations in both canaliculi. Five patients (20.83 %) had concomitant orbital fractures, and three patients (12.5 %) underwent additional repair for corneoscleral laceration. Bicanalicular silicone tube intubation was performed in one patient, while Mini-Monoka stent intubation was used for all other patients. The mean follow-up period was 41 ± 22.3 months, and the mean interval between trauma and surgery was 30.2 ± 29 h. The mean duration until tube removal was 3 ± 2.54 months. The MUNK score was 1 in eight patients (33 %) and 0 in sixteen patients (67 %). Canalicular lacerations occurred due to home accidents in 8 patients, work accidents in 4, assaults in 5, and traffic accidents in 7. Dacryoscintigraphy showed drainage of tracer into the nasal cavity in dynamic imaging for 12 patients. Five patients had retention in the sac, four had prolonged and reduced drainage, one had reduced drainage, and two showed no drainage in the first and second hour images. In the operated eye, the mean tear meniscus height (TMH) was 279.6 µm, depth (TMD) was 215 µm, and area (TMA) was 28.9 µm². In the healthy eye, the mean TMH was 221.5 µm, TMD was 152.5 µm, and TMA was 15.3 µm². The anterior segment OCT values for the affected eye were statistically significantly higher than those for the healthy eye (p = 0.044 for TMH, p = 0.003 for TMD, p = 0.006 for TMA). TMD and TMA were statistically significantly higher in patients with a MUNK score of 1 (p = 0.019 for TMD, p = 0.05 for TMA). Abnormal dacryoscintigraphy results were more common in patients with globe injuries requiring additional surgery.

CONCLUSION

Although patients did not report epiphora after canalicular laceration repair, our observations indicated potential functional and anatomical differences in dacryoscintigraphy and anterior segment OCT compared to their healthy eyes. We believe that close follow-up is crucial to identify and address any issues that may arise in the future following surgery.

In Vivo Quantification of Anterior and Posterior Chamber Volumes in Mice: Implications for Aqueous Humor Dynamics

Purpose

Aqueous humor inflow rate, a key parameter influencing aqueous humor dynamics, is typically measured by fluorophotometry. Analyzing fluorophotometric data depends, inter alia, on the volume of aqueous humor in the anterior chamber but not the posterior chamber. Previous fluorophotometric studies of the aqueous inflow rate in mice have assumed the ratio of anterior:posterior volumes in mice to be similar to those in humans. Our goal was to measure anterior and posterior chamber volumes in mice to facilitate better estimates of aqueous inflow rates.

Methods

We used standard near-infrared (NIR) optical coherence tomography (OCT) and robotic visible-light OCT (vis-OCT) to visualize, reconstruct, and quantify the volumes of the anterior and posterior chambers of the mouse eye in vivo. We used histology and micro-computed tomography (CT) scans to validate relevant landmarks from ex vivo tissues and facilitate in vivo measurement.

Results

Posterior chamber volume is 1.1 times the anterior chamber volume in BALB/cAnNCrl mice, that is, the anterior chamber constitutes about 47% of the total aqueous humor volume, which is very dissimilar to the situation in humans. Anterior chamber volumes in 2-month-old BALB/cAnNCrl and C57BL6/J mice were 1.55 ± 0.36 µL (n = 10) and 2.05 ± 0.25 µL (n = 10), respectively. This implies that previous studies likely overestimated the aqueous inflow rate by approximately twofold.

Conclusions

It is necessary to reassess previously reported estimates of aqueous inflow rates and, thus, aqueous humor dynamics in the mouse. For example, we now estimate that only 0% to 15% of aqueous humor drains via the pressure-independent (unconventional) route, similar to that seen in humans and monkeys.

Tear meniscus particle analysis with anterior segment optical coherence tomography in keratoconus

PURPOSE

To perform tear meniscus particle analysis using anterior segment spectral domain-optical coherence tomography (SD-OCT) and ImageJ software in keratoconus patients.

METHODS

A total of 76 participants (76 eyes) were included in the study. A comprehensive analysis of tear meniscus parameters, including tear meniscus height (TMH), tear meniscus depth (TMD), tear meniscus turbidity (TMT), and percentage of area occupied by particles (PAOP) within the meniscus, was performed in kerataconus patients and healthy controls.

RESULTS

TMT was significantly higher in the keratoconus group, while PAOP was significantly lower (P < 0.05). However, TMH and TMD did not show significant differences between the two groups (P > 0.05). There was a negative correlation observed between TMT and PAOP. In binary logistic regression analysis, TMT and Schirmer score were found to be the most influential factors in predicting keratoconus (odds ratio [OR] = 0.995, P = 0.039 and OR = 1.143, P = 0.021, respectively).

CONCLUSION

This study revealed novel findings on analysis of the tear film in keratoconus patients, with higher TMT and lower POAP levels in the keratoconus group compared to the healthy control group.

Corneal Epithelial Thickness in Sjogren's Disease: A Pilot Study

Purpose

This study was to assess corneal epithelial thickness (CET) in patients with Sjogren's disease (SjD).

Methods

A retrospective chart review was conducted of SjD patients from September 2021 to January 2022. Patient demographics, unanesthetized Schirmer's test, serologic markers, and symptoms as measured by the Ocular Surface Disease Index (OSDI) were reviewed. Epithelial thickness from both eyes was measured using anterior segment OCT at the central 3mm and concentric 5mm, 7mm, and 9mm zones for the superior, temporal, inferior, and nasal corneal quadrants. Associations between corneal epithelial thickness with patient demographics, clinical characteristics, and symptoms were evaluated using regression models.

Results

Fifteen SjD patients (100% female) were included with a mean age of 58.4 years. Patients with Sjogren's disease had a significantly thinner superior corneal epithelium compared to the inferior epithelium (mean 47.7mm vs 53.1mm, p = 0.001). The epithelial thickness mean standard deviation (MSD) was significantly inversely correlated with the unanesthetized Schirmer test (r=-0.39, p = 0.005), suggesting that an overall variability of CET correlates with decreased aqueous tear production. SS-A, SS-B, ANA, and RF positivity were not associated with any measures of CET.

Conclusion

This pilot study suggests that there is significant superior versus inferior thinning of corneal epithelium in Sjogren's patients. There was a significant correlation between variability of corneal epithelial thickness and decreased tear production in Sjogren's patients. Further larger studies are needed to understand the relationship of CET with objective and subjective measurements of ocular surface disease.

Anterior chamber and angle characteristics in Chinese children (6-11 years old) with different refractive status using swept-source optical coherence tomography

BACKGROUND

The anatomic structure of the anterior chamber (AC) helps to explain differences in refractive status in school-aged children and is closely associated with primary angle closure (PAC). The aim of this study was to quantify and analyze the anterior chamber and angle (ACA) characteristics in Chinese children with different refractive status by swept-source optical coherence tomography (SS-OCT).

METHODS

In a cross-sectional observational study, 383 children from two primary schools in Shandong Province, China, underwent a complete ophthalmic examination. First, the anterior chamber depth (ACD), anterior chamber width (ACW), angle-opening distance (AOD), and trabecular-iris space area (TISA) were evaluated automatically using a CASIA2 imaging device. AOD and TISA were measured at 500, 750 μm nasal (N1 and N2, respectively), and temporal (T1 and T2, respectively) to the scleral spur (SS). Cycloplegic refraction and axial length (AL) were then measured. According to spherical equivalent refraction (SER), the children were assigned to hyperopic (SER > 0.50D), emmetropic (-0.50D < SER ≤ 0.50D), and myopic groups (SER ≤ -0.50D).

RESULTS

Out of the 383 children, 349 healthy children (160 girls) with a mean age of 8.23 ± 1.06 years (range: 6-11 years) were included. The mean SER and AL were - 0.10 ± 1.57D and 23.44 ± 0.95 mm, respectively. The mean ACD and ACW were 3.17 ± 0.24 mm and 11.69 ± 0.43 mm. The mean AOD were 0.72 ± 0.25, 0.63 ± 0.22 mm at N1, T1, and 0.98 ± 0.30, 0.84 ± 0.27 mm at N2, T2. The mean TISA were 0.24 ± 0.09, 0.22 ± 0.09mm2 at N1, T1, and 0.46 ± 0.16, 0.40 ± 0.14mm2 at N2, T2. The myopic group had the deepest AC and the widest angle. Compared with boys, girls had shorter AL, shallower ACD, narrower ACW, and ACA (all p < 0.05). By Pearson's correlation analysis, SER was negatively associated with ACD, AOD, and TISA. AL was positively associated with ACD, ACW, AOD, and TISA. In the multiple regression analysis, AOD and TISA were associated with deeper ACD, narrower ACW, and longer AL.

CONCLUSION

In primary school students, the myopic eyes have deeper AC and wider angle. ACD, ACW, AOD, and TISA all increase with axial elongation. ACA is highly correlated with deeper ACD.

Algorithm and software for field distortion correction in a commercial SD-OCT for corneal curvature assessment

Accurate assessment of corneal curvatures using frequency domain optical coherence tomography (OCT) with galvanometer scanners remains challenging due to the well-known scan field distortion. This paper presents an algorithm and software for correcting the distortion using only two simple measurements in which a readily available standard sphere is positioned in different depths in front of the OCT scanner. This offers a highly accessible and easily reproducible method for the field distortion correction (FDC). The correction was validated by measuring different spherical phantoms and conducting corneal curvature measurements of ex vivo porcine corneas using a commercial spectral-domain OCT system and a clinically approved swept-source OCT as a reference instrument. Thus, the error in radius measurements of spherical phantoms was reduced by >90% and astigmatism by >80% using FDC. In explanted porcine eyes, the error in astigmatism measurements with the Telesto was reduced by 75% for power and 70% for angle. The best fitting sphere radius was determined up to a deviation of 0.4% from the Anterion. This paper describes a correction algorithm for OCT immanent distortion that is applicable to any scanning OCT setup and enables precise corneal curvature measurements. The MATLAB software for the FDC is publicly available on GitHub.

Comparison of different corneal imaging modalities using artificial intelligence for diagnosis of keratoconus: a systematic review and meta-analysis

PURPOSE

This review was designed to compare different corneal imaging modalities using artificial intelligence (AI) for the diagnosis of keratoconus (KCN), subclinical KCN (SKCN), and forme fruste KCN (FFKCN).

METHODS

A comprehensive systematic search was conducted in scientific databases, including Web of Science, PubMed, Scopus, and Google Scholar based on the PRISMA statement. Two independent reviewers assessed all potential publications on AI and KCN up to March 2022. The Critical Appraisal Skills Program (CASP) 11-item checklist was used to evaluate the validity of the studies. Eligible articles were categorized into three groups (KCN, SKCN, and FFKCN) and included in the meta-analysis. The pooled estimate of accuracy (PEA) was calculated for all selected articles.

RESULTS

The initial search yielded 575 relevant publications, of which 36 met the CASP quality criteria and were included in the analysis. Qualitative assessment showed that Scheimpflug and Placido combined with biomechanical and wavefront evaluations improved KCN detection (PEA, 99.2, and 99.0, respectively). The Scheimpflug system (92.25 PEA, 95% CI, 94.76-97.51) and a combination of Scheimpflug and Placido (96.44 PEA, 95% CI, 93.13-98.19) had the highest diagnostic accuracy for the detection of SKCN and FFKCN, respectively. The meta-analysis outcomes showed no significant difference between the CASP score and accuracy of the publications (all P > 0.05).

CONCLUSIONS

Simultaneous Scheimpflug and Placido corneal imaging methods provide high diagnostic accuracy for early detection of keratoconus. The use of AI models improves the discrimination of keratoconic eyes from normal corneas.

Applications of Imaging Technologies in Fuchs Endothelial Corneal Dystrophy: A Narrative Literature Review

Fuchs endothelial corneal dystrophy (FECD) is a complex genetic disorder characterized by the slow and progressive degeneration of corneal endothelial cells. Thus, it may result in corneal endothelial decompensation and irreversible corneal edema. Moreover, FECD is associated with alterations in all corneal layers, such as thickening of the Descemet membrane, stromal scarring, subepithelial fibrosis, and the formation of epithelial bullae. Hence, anterior segment imaging devices that enable precise measurement of functional and anatomical changes in the cornea are essential for the management of FECD. In this review, the authors will introduce studies on the application of various imaging modalities, such as anterior segment optical coherence tomography, Scheimpflug corneal tomography, specular microscopy, in vitro confocal microscopy, and retroillumination photography, in the diagnosis and monitoring of FECD and discuss the results of these studies. The application of novel technologies, including image processing technology and artificial intelligence, that are expected to further enhance the accuracy, precision, and speed of the imaging technologies will also be discussed.

Evaluation of Mooren's corneal ulcer by anterior segment optical coherence tomography

BACKGROUND

This study evaluates the use of anterior segment optical coherence tomography (AS-OCT) to identify focal changes and inform surgical plans in eyes with Mooren's ulcer.

METHODS

A total of 18 eyes of 17 patients with Mooren's ulcer were examined prospectively using the AS-OCT system.

RESULTS

Optical hyperreflectivity noted on AS-OCT images was in accordance with corneal ulceration, neovascularization, fibrovascular membranes, the junction of the native stromal bed, and the overlying lamellar corneal grafts. Focal corneal ectasia was observed in 13 eyes with a decrease in corneal thickness to ≤0.39 mm. There was a cut-off value of 0.39 mm in corneal thickness between the eyes with and without focal corneal ectasia in the thinned corneal area (Fisher = 0.383, χ2 = 14.873, P = 0.000). Based on the AS-OCT findings, six eyes were subjected to an individualized lamellar corneal graft. The thickness of the residual cornea after surgery was 47 ± 34 μm less than the presumed healthy corneal thickness before surgery (t = 3.376, P = 0.02). A small corneal perforation covered by a pseudopterygium in Mooren's ulcer was found through AS-OCT but undetectable by slit-lamp biomicroscopy.

CONCLUSIONS

AS-OCT is a valuable non-contact technique for monitoring corneal thinning in Mooren's ulcer, and assisting surgical design. A decrease in peripheral corneal thickness to ≤0.39 mm may cause focal corneal ectasia.

Evaluation of scleral thickness in patients with Fuchs endothelial dystrophy

PURPOSE

To evaluate scleral thickness using anterior segment-optical coherence tomography (AS-OCT) in Fuchs endothelial dystrophy (FED) and compare the results with healthy individuals.

METHODS

Thirty-two eyes of 32 patients with FED and 30 eyes of 30 age, gender, spherical equivalent and axial length matched healthy participants were included. All subjects underwent a detailed ophthalmological examination including endothelial cell density and central corneal thickness (CCT) measurements. Scleral thickness was measured by AS-OCT (Swept Source-OCT, Triton,Topcon,Japan) in 4 quadrants (superior, inferior, nasal, temporal) from 6 mm posterior to the scleral spur.

RESULTS

The mean ages were 62.5 ± 13.2 (33-81) for FED group; 64 ± 8.1 (48-81) for control group. CCT was significantly greater in FED group than in the control group (586.8 ± 33.1 (514-635) vs 545.0 ± 20.7 (503-587), respectively)(p = 0.000). In FED group, mean scleral thickness in the superior, inferior, nasal and temporal quadrants were 434.0 ± 30.6 (371-498), 442.8 ± 27.6 (395-502), 447.7 ± 31.4 (382-502), 443.4 ± 30.3 (386-504) μm, respectively. In control group, the mean scleral thickness in the superior, inferior, nasal and temporal quadrants were 381.3 ± 20.0 (341-436), 383.2 ± 16.0 (352-436), 389.2 ± 21.0 (353-440), 383.2 ± 19.2 (349-440) µm, respectively. The mean scleral thickness was significantly higher in all quadrants in FED group than in control group (p = 0.000).

CONCLUSION

In patients with FED, scleral thickness was significantly higher. FED is a progressive corneal disease that results in the accumulation of extracellular material in the cornea. These findings suggest that the accumulation of extracellular deposits may not be limited to the cornea. Due to their functional similarity and anatomical proximity, sclera may also be affected in FED.

Role of Fibroblast Growth Factor Receptor 2 (FGFR2) in Corneal Stromal Thinning

Purpose

To determine the role of fibroblast growth factor receptor 2 (FGFR2)-mediated signaling in keratocytes during corneal development, a keratocyte-specific FGFR2-knockout (named FGFR2cKO) mouse model was generated, and its phenotypic characteristics were determined.

Methods

A FGFR2cKO mouse model was generated by the following method: FGFR2 flox mice were crossed with the inducible keratocyte specific-Cre mice (Kera-rtTA/tet-O-Cre). Both male and female FGFR2cKO- and control mice (1 to 3-months-old) were analyzed for changes in corneal topography and pachymetry maps using the optical coherence tomography (OCT) method. The comparative TUNEL assay and immunohistochemical analyses were performed using corneas of FGFR2cKO and control mice to determine apoptotic cells, and expression of collagen-1 and fibronectin. Transmission electron microscopic analysis was conducted to determine collagen structures and their diameters in corneas of FGFR2cKO and control mice.

Results

OCT-analyses of corneas of FGFR2cKO mice (n = 24) showed localized central thinning and an increased corneal steepness compared to control mice (n = 23). FGFR2cKO mice further showed a decreased expression in collagen-1, decreased collagen diameters, acute corneal hydrops, an increased fibronectin expression, and an increased number of TUNEL-positive cells suggesting altered collagen structures and keratocytes' apoptosis in the corneas of FGFR2cKO mice compared to control mice.

Conclusions

The FGFR2cKO mice showed several corneal phenotypes (as described above in the results) that are also exhibited by the human keratoconus corneas. The results suggested that the FGFR2cKO mouse model serves to elucidate not only the yet unknown role of FGFR2-mediated signaling in corneal physiology but also serves as a model to determine molecular mechanism of human keratoconus development.

Changes in Anterior Segment Morphology and Intraocular Pressure after Cataract Surgery in Non-glaucomatous Eyes

BACKGROUND

It is known that cataract extraction is associated with a significant reduction in intraocular pressure, especially in narrow angled eyes; however, the modifications of anterior segment parameters associated with this phenomenon have still not been completely defined. The purpose of this study was to evaluate changes in anterior segment anatomy and intraocular pressure after cataract surgery in non-glaucomatous eyes.

METHODS AND MATERIAL

This retrospective case series study included 64 eyes of 64 consecutive patients who underwent phacoemulsification with intraocular lens implantation. Anterior segment parameters and intraocular pressure were assessed and compared before and 6 months after surgery. Anterior segment imaging was performed using Casia SS-1000 anterior segment optical coherence tomography (Tomey, Nagoya, Japan). Anterior segment measurements included anterior chamber depth, anterior chamber width, anterior chamber volume, angle opening distance at 500 µm anterior to the scleral spur, angle recess area 750 µm from the scleral spur, lens vault, trabecular iris space area at 500 µm from the scleral spur, and trabecular iris angle at 500 µm from the scleral spur. Intraocular pressure was measured using the Goldmann applanation tonometer (Model AT 900 C/M, Haag-Streit, Bern, Switzerland). Anterior segment parameters and the relationship of changes in intraocular pressure were also evaluated.

RESULTS

All anterior segment parameters increased significantly after surgery (p < 0.05). Both angle opening distance at 500 µm anterior to the scleral spur and anterior chamber depth changes were positively correlated with the preoperative lens vault. The mean intraocular pressure significantly decreased from 14.91 mmHg (± 2.8 SD) to 12.91 mmHg (± 3.13 SD) (p < 0.001). Changes in intraocular pressure correlated negatively with values for the width of the preoperative anterior chamber (r = - 0.533; p = 0.001).

CONCLUSION

Cataract surgery led to significant widening of the anterior chamber angle and lowering of intraocular pressure. Further investigations are needed to better understand whether anterior chamber width may be a new independent predictive factor for reduction in postoperative intraocular pressure.

Anterior segment optical coherence tomography characteristics of conjunctival papilloma as compared to papilliform ocular surface squamous neoplasia

PURPOSE

To describe the anterior segment optical coherence tomography (AS-OCT) appearance of conjunctival papilloma and identify differentiating features from papilliform ocular surface squamous neoplasia (OSSN).

METHOD

A retrospective chart review of individuals clinically diagnosed with conjunctival papilloma (n = 10) or papilliform OSSN (n = 10) based on slit lamp features. Data on demographics, tumour characteristics, and primary treatment were collected. AS-OCT features were assessed including epithelial thickness and reflectivity, a corrugated epithelial surface, presence of an overhanging edge, presence of intrinsic spaces and posterior shadowing. Histopathology was available in 5 papilloma and 3 OSSN specimens.

RESULT

Overall, the majority of individuals in both groups were white males. OSSN lesions were more likely to involve the limbus (80% vs.10%, p = 0.005) and the bulbar conjunctiva (100% vs. 20%, p < 0.001) compared to papillomas. On AS-OCT, maximum epithelial thickness was thicker in papilloma compared to OSSN (936 ± 533 vs. 637 ± 207 µm, p = 0.009). The feature that best differentiated papilloma from OSSN was an overhanging edge (100% vs. 0%, p < 0.001), where the epithelial lesion was seen on top of underlying normal epithelium. Other features more common in papilloma compared to OSSN included a corrugated epithelial surface (70% vs.10%, p = 0.02), the presence of intrinsic spaces (100% vs. 50%, p = 0.03), and posterior shadowing (100% vs. 40%, p = 0.01).

CONCLUSION

AS-OCT shows differentiating features between papilloma and OSSN with an overhanging edge as a distinctive AS-OCT feature of papilloma.

Integration of Artificial Intelligence into the Approach for Diagnosis and Monitoring of Dry Eye Disease

Dry eye disease (DED) is one of the most common diseases worldwide that can lead to a significant impairment of quality of life. The diagnosis and treatment of the disease are often challenging because of the lack of correlation between the signs and symptoms, limited reliability of diagnostic tests, and absence of established consensus on the diagnostic criteria. The advancement of machine learning, particularly deep learning technology, has enabled the application of artificial intelligence (AI) in various anterior segment disorders, including DED. Currently, many studies have reported promising results of AI-based algorithms for the accurate diagnosis of DED and precise and reliable assessment of data obtained by imaging devices for DED. Thus, the integration of AI into clinical approaches for DED can enhance diagnostic and therapeutic performance. In this review, in addition to a brief summary of the application of AI in anterior segment diseases, we will provide an overview of studies regarding the application of AI in DED and discuss the recent advances in the integration of AI into the clinical approach for DED.

Split-Window OCT biometry in pseudophakic eyes

PURPOSE

To determine the utility of Split-Window optical coherence tomography OCT (SW-OCT) biometry in measuring ocular axial dimensions as well as imaging the intraocular lens (IOL) and posterior capsule in pseudophakic eyes.

METHODS

Sixty-nine pseudophakic eyes of 69 subjects were enrolled in the study. The results of SW-OCT biometry implemented in the SD OCT device for posterior and anterior segment imaging (REVO NX, Optopol Technology) were compared with those obtained with the SS-OCT-based biometer IOLMaster 700 (Carl Zeiss Meditec). Differences in measurement values between the two biometers were determined using the paired t-test. Agreement was assessed through intraclass correlation coefficients (ICC) and Bland-Altman plots.

RESULTS

The correlation between measurements obtained with SW-OCT and SS-OCT was very high (ICC for: axial length (AL) = 1.000; anterior chamber depth (ACD) = 0.997; IOL thickness (IOL LT) = 0.997; central corneal thickness (CCT) = 0.987). The mean AL measurement difference was 0.003 ± 0.021 mm (the 95% LoA ranged from -0.04 to 0.05); the mean ACD difference was -0.009 ± 0.025 mm (95% LoA, -0.06 to 0.04); mean LT difference was 0.001 ± 0.021 mm (95% LoA, -0.04 to 0.04); and mean CCT difference was 1.4 ± 5.4 μm (95% LoA, -9 to 12).

CONCLUSION

The study shows small, non-significant differences between the biometric measurements obtained with REVO NX SW-OCT and IOLMaster 700 SS-OCT in pseudophakic eyes. However, SW-OCT offered significantly lower ACD and LT measurement failure rates. With high-resolution imaging, SW-OCT enables accurate assessment of IOL position relative to the posterior capsule and visualization of capsular fibrosis.

Nanoscale biomaterials for terahertz imaging: A non-invasive approach for early cancer detection

Terahertz (THz) technology is developing a non-invasive imaging system for biosensing and clinical diagnosis. THz medical imaging mainly benefits from great sensitivity in detecting changes in water content and structural variations in diseased cells versus normal tissues. Compared to healthy tissues, cancerous tumors contain a higher level of water molecules and show structural changes, resulting in different THz absorption. Here we described the principle of THz imaging and advancement in the field of translational biomedicine and early detection of pathologic tissue, with a particular focus on oncology. In addition, although the main forte of THz imaging relies on detecting differences in water content to distinguish the exact margin of tumor, THz displays limited contrast in living tissue for in-vivo clinical imaging. In the last few years, nanotechnology has attracted attention to aid THz medical imaging and various nanoparticles have been investigated as contrast enhancements to improve the accuracy, sensitivity, and specificity of THz images. Most of these multimodal contrast agents take advantage of the temperature-dependent of THz spectrum to the conformational variation of the water molecule. We discuss advances in developing THz contrast agents to accelerate the advancement of non-invasive THz imaging with improved sensitivity and specificity for translational clinical oncology.

The observation of anterior segment in children with an R124L mutation corneal dystrophy by anterior segment optical coherence tomography and in vivo confocal microscopy

Purpose

To evaluate the anterior segment in children with an R124L mutation corneal dystrophy (CD) using anterior segment optical coherence tomography (AS-OCT) and in vivo confocal microscopy (IVCM).

Methods

We investigated a family with prevalent CD and an R124L mutation; 59 individuals (14 patients; 6 male and 8 female, aged 2–69 years, 6 children, 2:4 male: female ratio) from four generations were included. We observed corneal lesions through ophthalmologic examinations, AS-OCT, and IVCM. The mean follow-up was 4.60 ± 3.91 years.

Results

The mean age for childhood CD onset was 0.90 ± 0.61 years. An Avelino DNA test revealed a heterozygous R124L mutation. Clinical manifestations included recurrent photophobia, tearing, and a foreign body sensation. Recurrence frequency decreased with age. Slit lamp microscopy revealed a rough corneal epithelium. The anterior matrix under the corneal epithelium and the anterior elastic layer were scattered with gray and white opacity. From onset to follow-up, the children’s visual acuity decreased from 0.34 ± 0.12 to 0.55 ± 0.17 LogMAR units. AS-OCT showed uneven corneal epithelial thickness. The Bowman’s layer was replaced by abnormal substances in the anterior segment. Corneal deposits became increasingly thicker; the average thickness at the last follow-up was 102.78 ± 10.13 μm. IVCM revealed uneven and reflective signals in the corneal upper cortex and subepithelium, with unclear boundaries and a loss of normal cell morphology.

Conclusion

We report an early age of onset in a family with prevalent CD due to R124L mutations. AS-OCT is a convenient, quick, and non-contact tool for screening and monitoring the pathological process of CD.

Imaging of iris vasculature: current limitations and future perspective

Fluorescein and indocyanine green angiography have been the traditional ways to image the vasculature of the iris in the last few decades. Because of the invasive nature of these procedures, they are performed in rare situations, and thus, our understanding about iris vasculature is very limited. Optical coherence tomography angiography (OCTA) is a noninvasive imaging method that enables the detailed visualization of the retinal and choroidal vascular networks. More recently, it has been also used for the examination of the iris vasculature in healthy and disease eyes. However, there is a lack of uniformity in the image acquisition protocols and interpretations in both healthy and pathological conditions. Artifacts of iris OCTA include shadowing, motion, segmentations errors, mirror effects. OCTA devices have an eye-tracking system designed for the posterior segment and the applications of these systems on the anterior segment can determine motion lines, vessel duplication, and vessel discontinuity. OCTA of the iris should always be performed under ambient room lighting to create miosis and reduce iris vasculature changes during the examination. In the near future, eye-tracking systems specifically designed for the iris vessels could permit the follow-up function, and the development of new OCTA metrics could reveal interesting applications of this new imaging technique.

Effects of Topical Antiglaucomatous Medications on Conjunctival Thickness: A Prospective Anterior Segment Optical Coherence Tomography Study

Purpose: Our aim was to evaluate the effects of topical antiglaucomatous medications on conjunctival thickness using anterior segment optical coherence tomography (AS-OCT). Methods: Thirty eyes of 30 patients with primary open angle glaucoma, who had never used any antiglaucomatous medications, enrolled in this prospective study. Followed by a full ophthalmologic examination, the conjunctival thickness was measured before treatment and at 1, 3, and 6-month post-treatment by AS-OCT. Measurements were taken from the superior bulbar conjunctiva, 3-4 mm from the limbus. Results: The mean age of patients was 67.7 ± 8.6; fourteen cases (46.7%) were given latanoprost, 2 cases (6.7%) brinzolamide+timolol, 2 cases (6.7%) betaxolol, 4 cases (13.3%) travoprost, and 8 cases (26.7%) brimonidine. The mean baseline conjunctival thickness was 222.9 ± 38 μm, while the mean conjunctival thickness was 212.8 ± 36.0 μm in the first month, 198.2 ± 35.8 μm in the third month, and 187.5 ± 40.2 μm in the sixth month. Decrease in conjunctival thickness at each examination was statistically significantly compared to baseline. (P < 0.05) Decrease in conjunctival thickness in Latanoprost subgroup was statistically significant, whereas the decreases in other active ingredients were not. Conclusions: Topical antiglaucomatous medications especially prostaglandin analogs may affect conjunctival thickness even during the first few months. This thinning effect may be crucial for the conjunctiva, as the basis of the possible filtration surgery.

Role of AS-OCT in Managing Corneal Disorders

Optical coherence tomography (OCT) is analogous to ultrasound biometry in the cross sectional imaging of ocular tissues. Development of current devices with deeper penetration and higher resolution has made it popular tool in clinics for visualization of anterior segment structures. In this review, the authors discussed the application of AS-OCT for diagnosis and management of various corneal and ocular surface disorders. Further, recent developments in the application of the device for pediatric corneal disorders and extending the application of OCT angiography for anterior segment are introduced.

Accuracy of the indices of MS-39 anterior segment optical coherence tomography in the diagnosis of keratoconic corneas

PURPOSE

To determine the normative and the cut-off values of various indices available in the MS 39 Anterior Segment Optical Coherence Tomography (MS-39 AS-OCT) for keratoconus (KC) diagnosis, and to detect the accuracy of the variable available parameters.

METHODS

This cross sectional observational study was conducted at Dr Rifay Ophthalmology Center, Rabat, Morocco, on 172 eyes with KC (group 1) and 248 eyes of healthy controls (group 2). Participants were screened using MS-39 AS-OCT (CSO, Firenze, Italy). The investigated indices included: keratometric indices, pachymetric indices, elevation indices, Keratoconus Summary Indices (KSI), aberration indices, and epithelial mapping evaluation.

RESULTS

Most of the studied indices were significantly different between both groups (P value <0.001). Twenty two indices had Area Under the Receiver Operating Curve (AUROC) values >0.950, eight of which were from the KSI. The indices with the highest AUROC values were: Root Mean Square (RMS) for the front corneal surface at 6 mm circle (AUROC = 0.996, and best cut-off >1.69 with sensitivity of 97.67% and specificity of 97.98%) and RMS per unit of area for the front surface at 6 mm circle (AUROC = 0.996, and best cut-off >0.06 with sensitivity of 97.67% and specificity of 97.98%). Epithelial thickness-derived metrics were not among the parameters with the highest accuracy.

CONCLUSIONS

This study presented the mean and the cut-off values for a plethora of parameters available in the MS-39 AS-OCT. The results of this study show that MS-39 AS-OCT is a valuable equipment for diagnosing keratoconic corneas, with a high accuracy detected for many parameters.

Corneal Eccentricity in a Rural Japanese Population: The Locomotive Syndrome and Health Outcome in Aizu Cohort Study (LOHAS)

PURPOSE

To determine normal corneal eccentricity in a rural Japanese population and to examine factors associated with eccentricity value.

METHODS

This used data from the Locomotive Syndrome and Health Outcome in Aizu Cohort Study (LOHAS) project between 2009 and 2012. Residents of Minamiaizu and Tadami in Fukushima, Japan, who were aged 40 years or over, were invited for a comprehensive eye examination. For 1371 patients with no history of internal eye surgery, corneal eccentricity was measured using a Pentacam.

RESULTS

Of 1371 people recruited to the study, 1215 (1215 eyes) met the inclusion criteria. The overall mean eccentricity was 0.46 (SD = 0.18; range, -0.85 to 0.88). Corneal eccentricity was significantly associated with age, spherical equivalent, pupil diameter, anterior chamber angle, anterior chamber volume, and central corneal thickness, but not with gender or body mass index.

CONCLUSIONS

In this study, the normal cornea in this Japanese population was prolate. Corneal eccentricity was likely to decrease with increasing age. Also, spherical equivalent and other anterior segment parameters had an influence on corneal eccentricity. Corneal eccentricity measurements might be helpful in the diagnosis of corneal diseases and in calculations for intraocular lens implantation and corneal refractive surgery.

The disposable bandage soft contact lenses therapy and anterior segment optical coherence tomography for management of ocular graft-versus-host disease

PURPOSE

To identify the ocular surface changes of ocular graft-versus-host disease (GVHD) using anterior segment optical coherence tomography (AS-OCT) and examine the efficacy of disposable bandage soft contact lens (BSCL) treatment in ocular GVHD patients.

METHODS

This study is a prospective, Phase II clinical trial. Nineteen patients diagnosed with chronic GVHD based on the NIH criteria and ocular symptoms of NIH eye score 2 or greater were enrolled. Disposable BSCL was applied to the GVHD-affected eyes with topical antibiotic coverage. Ocular exams, eye symptom surveys, and AS-OCT were performed with signed informed consent. Patients were followed for one to three months.

RESULTS

Thirty-eight eyes of 19 patients with ocular GVHD underwent BSCL treatment in this study. AS-OCT scans were done in 14 out of 19 patients. The mean best-corrected visual acuity at enrollment, 2-week, and 4-week visits was 0.180, 0.128, and 0.163 logMAR, respectively. Twenty-four out of 25 eyes (96 %) that initially presented with conjunctival inflammation, twenty-three out of 30 eyes (76.7 %) that initially presented with punctate epithelial erosion, and 8 out of 15 (53.3 %) eyes that initially presented with filamentous keratopathy showed improvement after wearing BSCL for 2 to 4 weeks. AS-OCT revealed corneal epithelial irregularity, abnormal meibomian gland orifice, and conjunctival hyperemia, in patients with ocular GVHD.

CONCLUSIONS

BSCL treatment provided significant subjective and objective improvements in ocular GVHD patients. Meanwhile, we found that AS-OCT can be a promising diagnostic tool to characterize the ocular surface changes associated with ocular GVHD.

The Value of Anterior Segment Optical Coherence Tomography in Different Types of Corneal Infections: An Update

Anterior segment optical coherence tomography (AS-OCT) is a modality that uses low-coherence interferometry to visualize and assess anterior segment ocular features, offering several advantages of being a sterile and noncontact modality that generates high-resolution cross-sectional images of the tissues. The qualitative and quantitative information provided by AS-OCT may be extremely useful for the clinician in the assessment of a wide spectrum of corneal infections, guiding in the management and follow-up of these patients. In clinical practice, infections are routinely evaluated with slit-lamp biomicroscopy, an examination and imaging modality that is limited by the physical characteristics of light. As a consequence, the depth of pathology and the eventually associated corneal edema cannot be accurately measured with the slit-lamp. Therefore, it represents a limit for the clinician, as in vivo information about corneal diseases and the response to treatment is limited. Resolution of corneal infection is characterized by an early reduction in corneal edema, followed by a later reduction in infiltration: both parameters can be routinely measured with standardized serial images by AS-OCT.

Repeatability of corneal and epithelial thickness measurements with anterior segment optical coherence tomography in keratoconus

PURPOSE

To investigate the repeatability in corneal thickness (CT) and epithelial thickness (ET) measurements using spectral domain anterior segment optical coherence tomography (AS-OCT, REVO NX, Optopol) in keratoconus, and examine the effect of corneal crosslinking (CXL) on repeatability.

METHODS

A cross-sectional study of 259 eyes of 212 patients with keratoconus attending the corneal disease clinic at a university hospital tertiary referral center were enrolled. Two groups were analysed: eyes with no prior history of CXL (Group A) and eyes with prior CXL (Group B). Repeatability of measurements was assessed using the intraclass correlation coefficient (ICC) and coefficient of variation (CV).

RESULTS

In Group A, central corneal thickness (CCT) was 472.18 ± 45.41μm, and the ET was found to be the thinnest in the inferior-temporal aspect at 51.79 ± 5.97μm and thickest at the superior-nasal aspect at 56.07 ± 5.70μm. In Group B, CCT was 465.11± 42.28μm, and the ET was the thinnest at the inferior-temporal aspect at 50.63 ± 5.52μm and thickest at the superior aspect at 56.80 ± 6.39μm. When evaluating CT measurements, ICC was above 0.86 and 0.83 for Group A and Group B respectively. When evaluating ET measurements, ICC was above 0.82 for both groups. CXL had no statistically significant impact on the repeatability of measurements.

CONCLUSIONS

AS-OCT provides repeatable CT and ET measurements in the central and peripheral cornea in patients with keratoconus. Repeatability is not affected by a history of CXL.

Establishing an objective biomarker for corneal cystinosis using a threshold-based Spectral domain optical coherence tomography imaging algorithm

PURPOSE

The purpose of the present study was to establish a semi-automated threshold-based image segmentation algorithm to detect and objectively quantify corneal cystine crystal deposition in ocular cystinosis with anterior segment optical coherence tomography (AS-OCT).

METHODS

This prospective, observational, comparative study included 88 eyes of 45 patients from the German Cystinosis Registry Study as well as 68 eyes of 35 healthy control subjects. All eyes were imaged with AS-OCT (Cirrus HD-OCT 5000, Carl Zeiss Meditec AG, Jena, Germany). As an initial step, B-scan images were subjectively analysed for typical changes in morphology in comparison to healthy controls. Based on the experience gained, an objective semi-automated B-scan image segmentation algorithm was developed using a grey scale value-based threshold method to automatically quantify corneal crystals.

RESULTS

On AS-OCT B-scans, corneal crystals appeared as hyperreflective deposits within the corneal stroma. The crystals were distributed either in all stromal layers (43 eyes, 49%) or confined to the anterior (23 eyes, 26%) or posterior stroma (22 eyes, 25%), respectively. The novel automatic B-scan image segmentation algorithm was most efficient in delineating corneal crystals at higher grey scale thresholds (e.g. 226 of a maximum of 255). Significant differences in suprathreshold grey scale pixels were observable between cystinosis patients and healthy controls (p < 0.001). In addition, the algorithm was able to detect an age-dependent depth distribution profile of crystal deposition.

CONCLUSION

Objective quantification of corneal cystine crystal deposition is feasible with AS-OCT and can serve as a novel biomarker for ocular disease control and topical treatment monitoring.

Safety profiles of terahertz scanning in ophthalmology

Terahertz (THz) technology has emerged recently as a potential novel imaging modality in biomedical fields, including ophthalmology. However, the ocular biological responses after THz electromagnetic exposure have not been investigated. We conducted a rabbit study to evaluate the safety profiles of THz scanning on eyes, at a tissue, cellular, structural and functional level. Eight animals (16 eyes) were analysed after excessive THz exposure (control, 1 h, 4 h, and 1 week after continuous 4-h exposure; THz frequency = 0.3 THz with continuous pulse generated at 40 µW). We found that at all the time points, the corneas and lens remained clear with no corneal haze or lens opacity formation clinically and histopathologically. No thermal effect, assessed by thermographer, was observed. The rod and cone cell-mediated electroretinography responses were not significantly altered, and the corneal keratocytes activity as well as endothelial viability, assessed by in-vivo confocal microscopy, was not affected. Post-exposed corneas, lens and retinas exhibited no significant changes in the mRNA expression of heat shock protein (HSP)90AB1), DNA damage inducible transcript 3 (DDIT3), and early growth response (EGR)1. These tissues were also negative for the inflammatory (CD11b), fibrotic (fibronectin and α-smooth muscle actin), stress (HSP-47) and apoptotic (TUNEL assay) responses on the immunohistochemical analyses. The optical transmittance of corneas did not change significantly, and the inter-fibrillar distances of the corneal stroma evaluated with transmission electron microscopy were not significantly altered after THz exposure. These results provide the basis for future research work on the development of THz imaging system for its application in ophthalmology.

In-vivo Three-dimensional Characteristics of Bowman's Layer and Endothelium/Descemet's Complex Using Corneal Microlayer Tomography in Healthy Subjects

Purpose: To characterize the three-dimensional (3D) thickness profile and age-related changes of Bowman's layer (BL), and endothelium/Descemet's membrane (En/DM) complex among healthy individuals using Corneal Microlayer Tomography (CML-T), and to describe its repeatability and accuracy.Methods: Sixty-six eyes of 41 healthy volunteers; 27 eyes (< 40 years old), and 39 eyes (>40 years old) were imaged using HD-OCT. Automatic and manual segmentation of the corneal layers was performed, and 3D thickness maps were generated, using custom-built CML-T software. A regional analysis of mean thickness parameters between the 2 age groups was performed. A regression analysis was used to assess the correlation between age, and thickness maps. Intraclass Correlation Coefficients (ICC), Coefficients of Variation (COV), and Bland-Altman plots were used to assess the reliability of the repeated measurements in 198 locations.Results: CML-T successfully mapped the BL and En/DM in all included eyes. Thickness maps showed a significant increase in corneal thickness (CT), BL thickness (BMT), and En/DM complex thickness (DMT) toward the periphery with a mean difference 28 µm (p < .001), 1.1 µm (p < .001), and 1.4 µm (p < .001), respectively. There was a strong correlation between age and central DMT (r = 0.61; p < .001), while there was no correlation between age and both CT, and BMT. ICC values ranged from 0.9 (BMT) to 0.997 (DMT), and from 0.808 (BMT) to 0.979 (CT) for intraoperator repeatability of manual measurements, and the accuracy of auto matic measurements, respectively. COV values were lower than 7.5% in all cases.Conclusion: CML-T is a novel tool that can generate 3D-thickness maps of both BL and En/DM. CT, BMT, and DMT increase toward the periphery in healthy corneas. DMT increases with aging, while BMT does not. We also report excellent repeatability, accuracy and good agreement between automatic and manual measurements.

PPIP5K2 and PCSK1 are Candidate Genetic Contributors to Familial Keratoconus

Keratoconus (KC) is the most common corneal ectatic disorder affecting >300,000 people in the US. KC normally has its onset in adolescence, progressively worsening through the third to fourth decades of life. KC patients report significant impaired vision-related quality of life. Genetic factors play an important role in KC pathogenesis. To identify novel genes in familial KC patients, we performed whole exome and genome sequencing in a four-generation family. We identified potential variants in the PPIP5K2 and PCSK1 genes. Using in vitro cellular model and in vivo gene-trap mouse model, we found critical evidence to support the role of PPIP5K2 in normal corneal function and KC pathogenesis. The gene-trap mouse showed irregular corneal surfaces and pathological corneal thinning resembling KC. For the first time, we have integrated corneal tomography and pachymetry mapping into characterization of mouse corneal phenotypes which could be widely implemented in basic and translational research for KC diagnosis and therapy in the future.

Automatic Identification and Representation of the Cornea-Contact Lens Relationship Using AS-OCT Images

The clinical study of the cornea-contact lens relationship is widely used in the process of adaptation of the scleral contact lens (SCL) to the ocular morphology of patients. In that sense, the measurement of the adjustment between the SCL and the cornea can be used to study the comfort or potential damage that the lens may produce in the eye. The current analysis procedure implies the manual inspection of optical coherence tomography of the anterior segment images (AS-OCT) by the clinical experts. This process presents several limitations such as the inability to obtain complex metrics, the inaccuracies of the manual measurements or the requirement of a time-consuming process by the expert in a tedious process, among others. This work proposes a fully-automatic methodology for the extraction of the areas of interest in the study of the cornea-contact lens relationship and the measurement of representative metrics that allow the clinicians to measure quantitatively the adjustment between the lens and the eye. In particular, three distance metrics are herein proposed: Vertical, normal to the tangent of the region of interest and by the nearest point. Moreover, the images are classified to characterize the analysis as belonging to the central cornea, peripheral cornea, limbus or sclera (regions where the inner layer of the lens has already joined the cornea). Finally, the methodology graphically presents the results of the identified segmentations using an intuitive visualization that facilitates the analysis and diagnosis of the patients by the clinical experts.

Use of High-Resolution Optical Coherence Tomography in the Surgical Management of Ocular Surface Squamous Neoplasia: A Pilot Study

PURPOSE

To evaluate whether high-resolution optical coherence tomography (HR-OCT) can detect histologic tumor margins of ocular surface squamous neoplasia (OSSN).

METHODS

Eight eyes of 8 patients with OSSN undergoing excision were studied prospectively. Immediately before surgery, the tumor was imaged using commercially available HR-OCT to identify the conjunctival margins of the neoplastic lesion. The tumor borders of the lesion determined by HR-OCT were mapped in relation to an anatomic reference point and transferred intraoperatively. The tumor was excised with 4-mm margins from the visible edge of the lesion with a "no-touch" technique. The specimens were sent for pathologic analysis and the histologic tumor margin was compared to the HR-OCT predicted tumor border.

RESULTS

Mean age of the 8 patients was 67 ± 9.9 years. Seven were male, 7 were white, and, ethnically, 3 were Hispanic. All 8 tumors were bulbar and in the exposure zone. Seven tumors were limbal. Corneal extension was present in 5. Mean tumor area was 17.5 ± 11.1 mm². Clinically, 2 of the tumors were leukoplakic, 1 papillomatous, and 3 gelatinous. A conjunctival tumor margin identified with the HR-OCT coincided with the pathologically confirmed margin mark in all eyes.

CONCLUSIONS

HR-OCT has the potential to predict histologic tumor margins in OSSN. Optical identification of tumor margins could potentially decrease the incidence of residual positive margins and minimize healthy tissue removal. Advances in HR-OCT technology and integration into a microscope for "real-time" imaging are needed to further improve this technique. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.

Assessment of tear meniscus by optical coherence tomography in patients with canalicular laceration repair

PURPOSE

To analyze tear meniscus measurements with optical coherence tomography (OCT) in patients with canalicular laceration repair.

METHODS

Thirty-four consecutive patients who underwent unilateral canalicular repair due to canalicular laceration between January 2014 and December 2018 were included. All patients had canalicular repair followed by monocanalicular or annular silicone tube intubation. Anatomic patency of canalicular system was tested with probing and irrigation, while functional patency was evaluated with Munk score. Tear meniscus measurements of all patients were obtained following tube removal by spectral OCT. Tear meniscus height (TMH), tear meniscus depth (TMD) and tear meniscus area (TMA) of eyes with canalicular laceration repair and contralateral uninvolved eyes were compared.

RESULTS

Average age of 34 patients was 32.8 ± 21.3 years (range 4-68 years). Lower canaliculus was involved in 27 (79.4%), upper canaliculus in five (14.7%), and both canaliculi in two (5.9%) patients. Mean follow-up period was 6.5 ± 5.7 months. Anatomic patency rate was 100%, and functional patency (patients free of epiphora) was 91.2%. Average TMH (317.9 ± 133.1 µm), TMD (198.1 ± 82.5 µm) and TMA (29,792.1 ± 21,285.3 μm²) values of eyes with canalicular repair were not significantly different from TMH (308.9 ± 111.9 µm), TMD (184.5 ± 61.4 µm) and TMA (26,682.5 ± 16,178.1 μm²) values of contralateral control eyes (p values: 0.758, 0.225 and 0.778, respectively). There was a strong positive correlation between TMA and Munk score (r = 0.637, p < 0.001) and moderate positive correlation between TMH (r = 521, p = 0.002), TMD (r = 0.481, p = 0.004) and Munk score.

CONCLUSION

Tear meniscus measurement with OCT is a rapid, quantitative and objective tool for evaluation of canalicular patency in patients with canalicular laceration repair.

In vivo two-photon microscopy of the human eye

Two-photon (2P) microscopy is a powerful tool for imaging and exploring label-free biological tissues at high resolution. Although this type of microscopy has been demonstrated in ex vivo ocular tissues of both humans and animal models, imaging the human eye in vivo has always been challenging. This work presents a novel compact 2P microscope for non-contact imaging of the anterior part of the living human eye. The performance of the instrument was tested and the maximum permissible exposure to protect ocular tissues established. To the best of our knowledge, 2P images of the in vivo human cornea, the sclera and the trabecular meshwork are shown for the very first time. Acquired images are of enough quality to visualize collagen arrangement and morphological features of clinical interest. Future implementations of this technique may constitute a potential tool for early diagnosis of ocular diseases at submicron scale.

Intraoperative Optical Coherence Tomography-Guided Femtosecond Laser-Assisted Deep Anterior Lamellar Keratoplasty

PURPOSE

To describe the feasibility and outcomes of intraoperative optical coherence tomography (OCT)-guided, femtosecond laser-assisted deep anterior lamellar keratoplasty in which the lamellar and tunnel cuts were completed by laser.

METHODS

The Ziemer Z8 system was used to scan the corneas intraoperatively and guide the stromal lamellar and tunnel cuts created by the laser. Thirty porcine eyes and 3 human cadaver globes were used to evaluate the accuracy of laser-created intrastromal tunnels and the feasibility of achieving big-bubble pneumatic dissection. The tunnel distance above the Descemet membrane (Dt-dm) was set at 100 and 130 μm, and the accuracy of laser cut was assessed by anterior segment OCT and histological sections. Fourteen patients with keratoconus or corneal scars were then included to evaluate the clinical outcomes.

RESULTS

The deviation from the targeted Dt-dm was 5.5% to 8.6% and 0.7% to 9.8% for the 100 and 130 μm groups, respectively. The achieved thickness had a significantly and positively strong correlation with the targeted thickness (r = 0.86; P < 0.001). In all cases, the anterior stromal lamella was removed without difficulty, except in the patients with corneal scars in whom some remaining stromal fiber attachments were observed. A type 1 big bubble was successfully achieved in all patients.

CONCLUSIONS

We present the accuracy and clinical outcomes of femtosecond laser-assisted, intraoperative OCT-guided deep anterior lamellar keratoplasty, in which controlled lamellar and tunnel cuts at desired depths were performed by laser in one step, and a successful big bubble was achieved.

Anterior Segment Optical Coherence Tomography: Applications for Clinical Care and Scientific Research

Anterior segment optical coherence tomography (AS-OCT) is a non-contact imaging technique that produces high-resolution images and quantitative measurements of the anterior segment and its anatomical structures. There has been rapid development of OCT technology over the past 2 decades, with the transition from time-domain to Fourier-domain OCT devices. By integrating these advancements in OCT technology, AS-OCT devices have evolved into versatile clinical and research tools for studies of the anterior segment and ocular surface. The primary purpose of this article was to review OCT technology and AS-OCT devices as well as applications of AS-OCT for clinical practice and scientific research. We first describe the different types of OCT technology, how they have been adapted for AS-OCT imaging, and differences between various AS-OCT devices. We then review the applications of AS-OCT for characterizing the anatomical structures of the anterior segment and aqueous outflow pathways, including the anterior chamber angle, trabecular meshwork, and Schlemm canal. We also describe glaucoma-related applications of AS-OCT imaging, which include evaluating patients for static and dynamic biometric risk factors of primary angle closure disease and assessing the efficacy of glaucoma interventions, such as laser peripheral iridotomy and glaucoma surgery. Finally, we review other clinical applications of AS-OCT imaging for detection and management of diseases of the ocular surface, cornea, and lens.

Corneal staining during cataract surgery: Natural course, ASOCT features, and preventive measures

We report the natural course of the accidental injection of trypan blue into the corneal stroma while performing a routine cataract surgery by a resident during a training session. The corneal staining resolved with conservative medical treatment over 7 weeks. This case describes the anterior segment optical coherence tomography (ASOCT) features of corneal staining. It emphasizes on the relatively benign nature of this dye and the follow-up course. Causes that may be responsible for this untoward complication are highlighted with the necessary preventive measures that need to be taken care are also discussed.

Optical Coherence Tomography-Guided Transepithelial Phototherapeutic Keratectomy for Central Corneal Opacity in the Pediatric Population

Purpose

To report the outcomes of optical coherence tomography- (OCT-) guided transepithelial phototherapeutic keratectomy (PTK) for central corneal opacity in the pediatric population.

Methods

The charts of 10 eyes of 8 children aged 9 to 17 with central corneal opacity from various pathologies who underwent a standardized OCT-guided transepithelial PTK technique at a single private practice institution were retrospectively reviewed. The corneal topographic findings, OCT measurements, and visual results with refractive outcomes were analyzed 6 months after the PTK treatment.

Results

All 10 eyes tolerated the procedure well without any significant intraoperative or postoperative complications. Uncorrected and best spectacle-corrected visual acuity (BSCVA) significantly improved postoperatively (p < 0.0001 and p=0.0045, respectively). The absolute value of spherical equivalent on cycloplegic refraction significantly improved postoperatively as well (p=0.0014), but there were no significant changes in topographic measurements. Seven out of the 10 eyes had complete resolution of the central corneal opacity on OCT imaging. None of the subjects lost any lines of BSCVA and developed recurrence of the corneal opacity from the primary disease condition or required keratoplasty during the follow-up period.

Conclusions

OCT-guided transepithelial PTK can provide excellent visual outcomes in pediatric patients with central corneal opacities.

Demarcation Line in the Human Cornea After Surface Ablation Observed by Optical Coherence Tomography and Confocal Microscopy

PURPOSE

To investigate the long-term changes in anterior corneal structure after surface ablation.

METHODS

In this retrospective study, patients who received surface ablation including laser-assisted subepithelial keratomileusis (LASEK) and epipolis laser in situ keratomileusis at the Department of Ophthalmology of Fudan University Eye and Ear, Nose and Throat (EENT) Hospital (Shanghai, People's Republic of China) were telephoned. Patients were asked to follow-up at the refractive center. Changes in the anterior cornea (from the epithelium to the anterior stroma) were examined by optical coherence tomography (OCT) and in vivo confocal microscopy.

RESULTS

Thirty-four eyes of 18 patients (10 years or more after operation), 16 eyes of 8 patients (4 years after operation), 12 eyes of 6 patients (1 year after operation), 8 eyes of 4 patients (6 months after operation), and 12 eyes of 6 patients (1 month after operation) were included. Under OCT, a smooth, continuous, and highly reflective demarcation line between the epithelial layer and the stroma was noted in all eyes that received surgeries more than 1 year previously. For eyes at 6 months after operation, the complete formation of this demarcation line was detected in 12.5% (1/8) of eyes and a partial formation of this demarcation line was observed in 87.5% (7/8) of eyes. A partial formation of this demarcation line was observed in 100% (12/12) of eyes in patients at 1 month after surgery.

CONCLUSIONS

A demarcation line in the human cornea can be detected after corneal surface ablation. It was completely formed around postoperative 6 to 12 months. The functions and components of this structure merit investigation.

Using Anterior Segment Optical Coherence Tomography to Monitor Disease Progression in Peripheral Ulcerative Keratitis

We report two cases of peripheral ulcerative keratitis (PUK) imaged with anterior segment optical coherence tomography (AS-OCT). The first patient had prolonged nonsteroidal anti-inflammatory drug use, while the second had inflammatory arthritis by laboratory findings without any systemic findings as well as possible concurrent tuberculosis. In both patients, AS-OCT demonstrated corneal thinning at the onset of the disease with improvement six months after initiation of intensive medical therapy. Our cases highlight the need for a multidisciplinary approach and careful monitoring in PUK cases, especially with objective measures such as corneal thickness assessed with AS-OCT.

Optical coherence tomography for ocular surface and corneal diseases: a review

The advent of optical coherence tomography (OCT) imaging has changed the way ophthalmologists image the ocular surface and anterior segment of the eye. Its ability to obtain dynamic, high and ultra-high resolution, cross-sectional images of the ocular surface and anterior segment in a noninvasive and rapid manner allows for ease of use. In this review, we focus on the use of anterior segment OCT, which provides an “optical biopsy” or in vivo imaging of various ocular surface and corneal pathologies, allowing the clinician to diagnose diseases otherwise not visualized by traditional methods. The utility of anterior segment OCT for various anterior segment pathologies is reviewed.

Topography-Guided Photorefractive Keratectomy in the Treatment of Corneal Scarring

PURPOSE

To report the outcome of topography-guided photorefractive keratectomy (TG-PRK) in the treatment of patients with corneal scarring.

METHODS

A retrospective, interventional case series including 6 eyes of 6 patients with corneal scarring and irregular astigmatism who underwent TG-PRK. The etiologies for scarring were: infectious corneal ulcers, foreign body trauma, LASIK flap buttonhole, and lamellar keratoplasties performed to correct corneal perforation secondary to corneal melting. Main outcome measures were corrected distance visual acuity, uncorrected distance visual acuity, manifest refraction, and corneal regularity on topography maps.

RESULTS

Average age was 56.5 ± 19.6 years and average follow-up time was 14.8 ± 6.1 months. Three patients had corneal scarring with cataract and underwent TG-PRK to achieve sufficient regularization of corneal astigmatism to enable the implantation of a toric intraocular lens (IOL). The three remaining patients had TG-PRK performed to improve visual acuity, and all had improvement in uncorrected (improvement between one and three Snellen lines) and corrected (improvement between two and three Snellen lines) distance visual acuity. There were no intraoperative or postoperative complications and no loss of visual acuity.

CONCLUSIONS

The use of TG-PRK for corneal scarring may improve visual acuity in selected cases, obviate the need for keratoplasty in some cases, and facilitate toric IOL implantation in some cases. [J Refract Surg. 2017;33(9):639-644.].

Two cases of very late-onset capsular bag distension syndrome

Purpose

We present two cases of late-onset capsular bag distension syndrome (CBDS).

Observations

Two female patients were referred with decreased visual acuity and blurred vision. They had both undergone uncomplicated phacoemulsification and intraocular lens implantation into the capsular bag, seven and 13 years prior.Slit-lamp biomicroscopy and anterior segment optical coherence tomography demonstrated milky fluid between the intraocular lens and posterior capsules, consistent with late-onset capsular bag distension syndrome. A 25-gauge pars plana vitrectomy surgery was performed on each patient.This turbid retrolental fluid was successfully aspirated with posterior capsulotomy using 25-gauge pars plana vitrectomy surgery.

Conclusions and importance

Late-onset capsular bag distension syndrome may occur up to 13 years following cataract surgery; the longest reported duration of onset. Anterior segment optical coherence tomography is useful in aiding diagnosis. Management with vitrectomy surgery has the advantages of complete clearance of the turbid fluid and microbial and pathological testing.

Characterizing human decellularized crystalline lens capsules as a scaffold for corneal endothelial tissue engineering

The idea of transplanting a sheet of laboratory-grown corneal endothelium dates back to 1978; however, the ideal scaffold is still lacking. We hypothesized that human crystalline lens capsules (LCs) could qualify as a scaffold and aimed to characterize the properties of this material for endothelial tissue engineering. LCs were isolated from donor eyes, stored at -80 °C, and decellularized with water and trypsin-EDTA. The decellularization was investigated by nuclear staining and counting and the capsule thickness was determined by optical coherence tomography and compared with Descemet's membrane (DM). Transparency was examined by spectrometry, and collagenase degradation was performed to evaluate its resistance to degradation. Cell-scaffold interaction was assessed by measuring focal adhesions surface area on LC and plastic. Finally, primary corneal endothelial cells were grown on LCs to validate the phenotype. Trypsin-EDTA decellularized most effectively, removing 99% of cells. The mean LC thickness was 35.76 ± 0.43 μm, whereas DM measured 25.93 ± 0.26 μm (p < .0001). Light transmission was 90% for both LC and DM. On a collagenase challenge, LC and amniotic membrane were digested after 13 hr, whereas DM was digested after 17 hr. The surface area of focal adhesions for cells grown on coated LCs was at least double that compared with other conditions, whereas tight junctions, ion pumps, and hexagonal morphology were well maintained when endothelial cells were cultured on LCs. In conclusion, LCs demonstrate excellent scaffolding properties for tissue engineering and sustain the cell phenotype and can be considered a suitable substrate for ocular tissue engineering or as a template for future scaffolds.

Evaluation of the iridocorneal angle with accommodation using optical coherence tomography

The changes in the iridocorneal angle structure during accommodation are assessed by means of anterior segment optical coherence tomography. Thirteen right eyes were included in the study. The device used for the measurement was the Visante^®omni system. The stimuli were set up at different vergences (0.0 D, -1.5 D, and -3.0 D). The angle opening distance 500 and 750, the trabecular iris space area 500 and 750, and the scleral spur angle parameters were assessed at the nasal and temporal regions. The results in the iridotrabecular angle comparing the three accommodative states of the eye did not yield any statistically significant difference at nasal or temporal angle sections. In light of our results and in the conditions of our study, the structures of the iridocorneal angle are not significantly changed with accommodation.