Post-LASIK corneal epithelial irregularities October consultation #1.

A 55-year-old man with a history of bilateral laser-assisted in situ keratomileusis (LASIK) and subsequent enhancement over 15 years ago presented to our facility to investigate refractive surgery options. The patient reported progressive blurring and fluctuation of vision and desired independence from contact lenses and spectacles. Uncorrected distance visual acuity (UDVA) was 20/30 -2.0 in the right eye and 20/400 in the left eye, corrected to 20/60 in the left eye. Manifest refraction was +0.75 -1.75 × 180 diopters (D) in the right eye and -3.50 -3.50 × 64 D in the left eye. Keratometry readings were 43.9/41.1 @ 25 in the right eye and 49.3/46.8 @ 2 in the left eye. On slitlamp examination, the patient showed diffuse subepithelial fibrosis and confluent circumferential elevation, respecting the LASIK flap margin and extending centrally into the visual axis (Figure 1JOURNAL/jcrs/04.03/02158034-202110000-00025/figure1/v/2021-09-20T141830Z/r/image-tiff). Fluorescein pooling was also observed. Anterior segment ocular coherence tomography (OCT) demonstrated subepithelial hyperreflective density in the left eye (Figure 2JOURNAL/jcrs/04.03/02158034-202110000-00025/figure2/v/2021-09-20T141830Z/r/image-tiff). Pentacam showed irregularity and inferior steepening up to 52.0 D (Figure 3JOURNAL/jcrs/04.03/02158034-202110000-00025/figure3/v/2021-09-20T141830Z/r/image-tiff). A review of the patient's records from 4 years ago revealed UDVA of 20/30 -2 in the right eye and 20/20 in the left eye with manifest refraction of +1.00 -1.50 × 30 D in the right eye and -0.25 D in the left eye. Keratometry then showed 39.52/40.91 @ 98 in the right eye and 39.85/40.42 @ 75 in the left eye. Patient's slitlamp examination revealed minimal subepithelial irregularity without endothelial changes in both eyes. At current presentation, the patient was not deemed a candidate for further refractive surgery given a low residual stromal bed after original LASIK with enhancement. The patient was seeking help and advice for his declining vision. What is the most likely diagnosis, and what other conditions are on your differential? What would be your next step? Would you request additional diagnostic workup? What medical and surgical interventions would you recommend?

Moshirfar M ，Bundogji N 《-》

Epithelial ingrowth after LASIK September consultation #1.

A 62-year-old woman presented to our clinic in April 2021 with a painful right eye and increased light sensitivity for 1 week, 30 years after laser in situ keratomileusis (LASIK) in both eyes for myopia of -2.5 diopters. There were no complaints of the left eye. There were no abnormalities in her medical history. The uncorrected distance visual acuity (UDVA) of the right eye at presentation was 20/20. Slitlamp biomicroscopy revealed epithelial ingrowth on the right eye with stromal edema and inflammation and fine keratic precipitates on the endothelium (Figures 1 and 2JOURNAL/jcrs/04.03/02158034-202109000-00024/figure1/v/2021-08-31T192739Z/r/image-tiffJOURNAL/jcrs/04.03/02158034-202109000-00024/figure2/v/2021-08-31T192739Z/r/image-tiff). The cornea of the left eye was unremarkable. The anterior chamber of the right eye showed 1 + cells (SUN grading). There were no abnormalities in the posterior segment. Figure 3JOURNAL/jcrs/04.03/02158034-202109000-00024/figure3/v/2021-08-31T192739Z/r/image-tiff shows the corneal epithelial ingrowth with a swept-source optical coherence tomography (OCT) and Figure 4JOURNAL/jcrs/04.03/02158034-202109000-00024/figure4/v/2021-08-31T192739Z/r/image-tiff an axial corneal Scheimpflug tomography map. What is your treatment advice for this patient from a short- and long-term perspective?

Nuijts RMMA ，Kartal S 《-》

Spontaneous filtering bleb with subsequent secondary glaucoma June consultation #1.

A 32-year-old previously healthy woman was referred for evaluation and management of newly diagnosed hypotony in the right eye. Her ocular history was significant only for moderate myopia and an idiopathic Horner syndrome in the left eye diagnosed at age 13. The patient endorsed a history of fluctuating and decreasing vision in the right eye over the past 6 months. She denied any ocular pain, previous ocular surgery, or recent trauma. The patient was otherwise healthy and denied any previous autoimmune disease or systemic infection. She wore soft, daily disposable contact lenses and reported no abnormalities on previous routine eye examinations. At presentation, the patient's uncorrected distance visual acuity was 20/25 in the right eye and 20/200 in the left. Lensometry revealed a previous refraction of -3.00 + 0.50× 150 in the right eye and -4.00 + 1.75× 174 in the left. Intraocular pressures (IOPs) were 4 mm Hg and 15 mm Hg by applanation, and central corneal thicknesses were 573 μm and 564 μm in the right and left eyes, respectively. Slitlamp examination revealed an area of scleral thinning near the limbus in the right eye from 5 to 7 o'clock with mild overlying chemosis (Figure 1JOURNAL/jcrs/04.03/02158034-202107000-00023/figure1/v/2021-06-26T110826Z/r/image-tiff). Gonioscopy showed an open angle with mild trabecular meshwork pigmentation in both eyes without any cyclodialysis clefts, peripheral anterior synechiae (PAS), or other abnormalities. Dilated fundus examination was significant for mild optic nerve edema and chorioretinal folds in the right eye. Optical coherence tomography (OCT) of the optic nerve confirmed mild disc edema (Figure 2JOURNAL/jcrs/04.03/02158034-202107000-00023/figure2/v/2021-06-26T110826Z/r/image-tiff) and OCT of the macula confirmed mild chorioretinal folds. Anterior segment OCT (AS-OCT) and ultrasound biomicroscopy failed to show any other abnormalities. The patient was initially observed without treatment and presented urgently approximately 1 month later with decreased vision and ocular discomfort. Repeat examination revealed an IOP of 31 mm Hg and a focal area of PAS to the previous area of scleral thinning (Figure 3JOURNAL/jcrs/04.03/02158034-202107000-00023/figure3/v/2021-06-26T110826Z/r/image-tiff). In one respect, the newly elevated IOP was considered transiently therapeutic to help reverse the hyperopic shift, disc edema, and hypotony-related maculopathy. However, the situation quickly became more worrisome when shortly thereafter the IOP elevated to 55 mm Hg at subsequent follow-up, and multiple IOP-lowering medications were initiated. Over numerous additional visits, the patient's IOPs ranged from 30 to 39 mm Hg in the right eye despite rapidly advancing to maximally tolerated medical therapy including acetazolamide. She was noted to have a new relative afferent pupillary defect of the right eye, and Humphrey visual fields showed early arcuate defects (Figure 4JOURNAL/jcrs/04.03/02158034-202107000-00023/figure4/v/2021-06-26T110826Z/r/image-tiff). What would be your approach to managing this healthy, young, myopic woman who presented with hypotony due to a spontaneous, perilimbal filtration bleb that later occluded with PAS, resulting in intractably elevated IOP and field loss? What is the differential diagnosis? Would you perform a systemic workup for her initial scleral thinning, and if so, what would you check? Would you intervene for her elevated IOP in the right eye? If so, what would be your surgical approach?

Berryman J ，Samuelson TW 《-》

Management of hypotony-related maculopathy after combined phacoemulsification and trabeculectomy: January consultation #1.

A 59-year-old man with mild to moderate pigmentary glaucoma was referred for management of hypotony-related maculopathy 3 years after combined phacoemulsification and trabeculectomy in his right eye. His ocular history is significant for retinal detachment in the right eye that was surgically treated with a pars plana vitrectomy and scleral buckle 5 years prior to the current presentation and 1 year prior to his combined phacoemulsification-trabeculectomy procedure. After trabeculectomy, he reportedly had a wound leak with hypotony and choroidal effusion. The patient was referred to a second surgeon who performed a bleb revision with a pericardial patch graft, but the patient had a severe intraocular pressure (IOP) spike in the immediate postoperative period requiring suture removal. This resulted in recurrent hypotony with maculopathy. A second bleb revision with pericardial patch graft was performed but was not successful in raising the IOP out of the single digits or in resolving the maculopathy. Accordingly, the patient was referred for further assessment. At presentation, the patient's corrected distance visual acuity was 20/100 in the right eye and 20/20 in the left eye. Applanation tonometry IOP was 4 mm Hg and 16 mm Hg for the right and left eyes, respectively. Central corneal thickness was 609 μm in the right eye and 574 μm in the left eye. The right pupil was noted to be slightly irregular with a relative afferent pupillary defect. Slitlamp examination of the right eye was notable for a moderately elevated, Seidel test-negative bleb, and deep anterior chamber. The left eye had a Krukenberg spindle and mild nuclear sclerotic cataract but was otherwise unremarkable. Fundus examination of the right eye was notable for significant macular folds with edematous nerve fiber layer (NFL) and optic nerve. The left optic nerve and fundus examination were unremarkable. Gonioscopy revealed open angles with dense trabecular meshwork pigment in both eyes. There was a nicely patent superior sclerostomy in the right eye. There was no cyclodialysis cleft. Optical coherence tomography (OCT) of the macula showed chorioretinal folds and NFL edema in the right eye and was normal in the left eye (Figure 1JOURNAL/jcrs/04.03/02158034-202101000-00022/figure1/v/2021-01-04T143903Z/r/image-tiff). The OCT of the optic nerve in the right eye was distorted secondary to the chorioretinal folds, whereas the left eye was notable for mild superior thinning of the NFL (Figure 2JOURNAL/jcrs/04.03/02158034-202101000-00022/figure2/v/2021-01-04T143903Z/r/image-tiff). Humphrey visual field revealed a superior nasal step in the right eye (Figure 3JOURNAL/jcrs/04.03/02158034-202101000-00022/figure3/v/2021-01-04T143903Z/r/image-tiff). Axial lengths were 25.33 mm and 26.53 mm in the right and left eye, respectively; it is notable that the right eye had a shorter axial length despite the scleral buckle, which demonstrates the degree of axial shortening from hypotony (Figure 4JOURNAL/jcrs/04.03/02158034-202101000-00022/figure4/v/2021-01-04T143903Z/r/image-tiff). What would be your approach for managing this patient's hypotony? Does the fact that the referring surgeon had performed 2 failed bleb revision procedures prior to referral influence your approach? Given that a previous attempt at revision resulted in an extreme IOP spike would you also recommend a glaucoma procedure? If so, what procedure would you perform? Would you do it coincident with the revision or in a staged procedure later on an as-needed basis?

Samuelson TW ，Liaboe C 《-》

Unilateral progressive epitheliopathy after LASIK.

Moshirfar M ，Hastings JP 《-》