BACKGROUND:To noninvasively quantify postoperative anterior chamber inflammation following corneal transplantation using Laser Flare Photometry (LFP), and to compare flare dynamics among three surgical techniques: deep anterior lamellar keratoplasty (DALK), Descemet stripping automated endothelial keratoplasty (DSAEK, including triple procedures), and penetrating keratoplasty (PK, including combined procedures). Particular attention was given to the incidence of cystoid macular oedema (CMO) and early immune-mediated graft reactions. The study also aimed to explore the role of LFP as a biomarker for individualised inflammatory risk stratification. METHODS:In this retrospective observational cohort study, 60 eyes of 60 patients who underwent corneal transplantation were allocated into three groups: DALK (n = 18), DSAEK (n = 24), and PK (n = 18). Aqueous flare was measured using LFP at baseline and on postoperative days 1, 7, 30, and 90. Primary outcomes included flare kinetics, surgical duration, CMO occurrence, and early signs of graft rejection. RESULTS:Mean aqueous flare peaked on day 1 in all groups: 50.9 ± 42.6 ph/ms in DALK, 70.0 ± 46.4 in DSAEK, and 79.0 ± 55.6 in PK. By day 90, flare returned near baseline in DALK (10.0 ± 4.7), while remaining mildly elevated in DSAEK (11.1 ± 10.0) and PK (12.8 ± 7.9). CMO developed in 5 eyes (1 DALK, 2 PK), and early graft reactions in 6 eyes (1 DALK, 3 DSAEK, 2 PK). CONCLUSIONS:This study highlights distinct inflammatory trajectories after corneal transplantation. LFP may serve as a valuable, non-invasive tool to monitor inflammation, guide personalised immunosuppression and prevent graft failure.

Background/AimsInfectious keratitis (IK) is a major cause of blindness worldwide, requiring prompt diagnosis and management. This study evaluates the diagnostic and evaluative roles of in vivo confocal microscopy (IVCM) and anterior segment optical coherence tomography (AS-OCT) in acute IK through correlating the characteristic imaging features of both modalities.Materials and methodsIn this prospective study, 35 eyes with severe IK of bacterial, fungal, Acanthamoeba, or mixed origin were examined using slit lamp biomicroscopy, microbiological culture, AS-OCT, and IVCM during the acute phase. Imaging parameters including tissue integrity, cellular infiltration, nerve presence, vascularisation, and microbial features were analysed. Quantitative cell density measurements and structural assessments were performed, with statistical comparisons between modalities and pathogen groups.ResultsIVCM effectively visualised cellular details, including keratocytes, inflammatory cells, nerve fibres, and specific organisms, with high sensitivity for detecting fungal filaments and Acanthamoeba cysts. AS-OCT provided high-resolution cross-sectional images, accurately measuring infiltrate depth, corneal thickness, and neovascularisation. IVCM was superior in identifying microbial elements, whereas AS-OCT excelled in assessing tissue architecture and oedema. Significant differences in cell densities were observed among pathogens, notably lower keratocyte density in Acanthamoeba keratitis. Both modalities were complementary, enhancing disease characterisation and monitoring.ConclusionsIVCM and AS-OCT are valuable, non-invasive tools that provide critical insights into IK. Their combined application improves early diagnosis, detailed evaluation, and treatment monitoring. Integration with artificial intelligence holds promise for further advances in precise, rapid diagnosis and personalised management of infectious keratitis.

Staphylococcus aureus is a leading cause of bacterial keratitis and antimicrobial resistance-associated death globally. This study aimed to evaluate the efficacy of CaD23, a human-derived hybrid antimicrobial peptide (AMP), in combination with antibiotics in treating S. aureus infections. The efficacy of CaD23 and six medically important antibiotics (amikacin, cefuroxime, chloramphenicol, fosfomycin, vancomycin and levofloxacin) was examined against six strains of methicillin-sensitive and methicillin-resistant S. aureus using a minimum inhibitory concentration (MIC) assay. CaD23-antibiotic interactions were evaluated using checkerboard and time-kill kinetics assays. 3,3'-dipropylthiadicarbocyanine iodide (DiSC3,5) cytoplasmic membrane depolarisation assay was performed to examine the mechanism of action. Overall, CaD23 exhibited good efficacy against all MSSA and MRSA (MIC = 16-32 μg/mL [6.7-13.3 μM]). Of 20 peptide-antibiotic-organism combinations, 19 (95%) combinations demonstrated positive interactions, with six (31.6%) and 13 (68.4%) exhibiting synergistic (FICI = 0.293-0.412) and additive effects (FICI = 0.521-0.890), respectively. CaD23 was able to achieve complete bacterial eradication significantly faster than cefuroxime and levofloxacin (15 min vs. 8-24 h). When used at a sub-MIC concentration, CaD23 could accelerate the killing of S. aureus of cefuroxime from 8-24 h to within 1 h and enhance the activity of levofloxacin by 90%. CaD23 was shown to rapidly depolarise the inner membrane of S. aureus within seconds of the treatment. In conclusion, CaD23-antibiotic combination therapy serves as a useful strategy for tackling drug-resistant ocular and systemic S. aureus infections.

ABSTRACT Background/Aims To evaluate the impact of socioeconomic deprivation on clinical presentation and outcomes of bacterial keratitis (BK) in the United Kingdom. Methods A retrospective multicentre cohort study of 320 patients with BK presenting to two UK tertiary ophthalmic centres. Demographic, clinical and microbiological data were extracted from electronic health records. Socioeconomic status was assigned using residential postcodes mapped to the 2019 English Index of Multiple Deprivation (IMD) and grouped into quintiles (Q1 most deprived; Q5 least deprived). Presenting severity and outcomes were compared across IMD quintiles. Results The mean age was 54.0±20.9 years; 50.6% were male and 83.4% were White. Mean presenting CDVA was 1.10±1.01 logMAR and time to presentation was a median of 3 days (IQR 1–6). Most cases had a small infiltrate (<3Lmm; 68.4%), small epithelial defect (<3Lmm; 63.4%) and no hypopyon (72.5%). Hospitalisation was required in 50.0%, and 17.5% underwent surgery. Culture positivity was 36.3%. There were no significant differences in presenting CDVA, time to presentation, clinical severity, admission, microbiological profile, surgical intervention or final CDVA across IMD quintiles (all p>0.05). Final CDVA improved to 0.75±0.96 logMAR (p<0.001). On multivariable analysis, poorer final CDVA was associated with worse presenting CDVA, increasing age and Gram-positive organisms, but not IMD. Conclusion Socioeconomic deprivation did not influence the clinical presentation or outcomes in BK. Clinical severity at presentation and microbiological profile were the principal determinants of outcome. In this acute, painful sight-threatening condition, deprivation-related disparities may be attenuated by prompt presentation and universal access to emergency ophthalmic care.

Background:Pseudomonas aeruginosa (PA) is a major cause of infectious keratitis worldwide. Contact lens (CL) wear is a key risk factor, though other predisposing factors exist. This study compared clinical features, risk factors, and outcomes of CL-related versus non-CL-related PA keratitis in the United Kingdom (UK). Methods:A retrospective cohort study of culture-confirmed PA keratitis cases that presented to the Birmingham and Midland Eye Centre (Birmingham, UK) and Queen's Medical Centre (Nottingham, UK) between August 2016 and January 2020. Demographics, clinical characteristics, risk factors, and outcomes were analysed and compared between CL-related and non-CL-related groups. Results:Sixty-six patients (66 eyes) were included; mean age was 54.0 ± 20.9 years and 59.1% were female. CL wear accounted for 35 (53.1%) cases. At presentation, mean CDVA was 1.26 ± 0.96 logMAR (~6/120 Snellen). Hospitalisation occurred in 71.2% cases, with 19.7% cases requiring surgery. Most isolated PA (64, 97.0%) were antibiotic-susceptible. Compared to non-CL-related keratitis, CL-related keratitis was more commonly associated with younger age, better initial vision, smaller and non-central ulcers, and absence of hypopyon (all p < 0.05). CL-related cases had a significantly lower risk of poor visual outcome (>0.6 logMAR; adjusted odd ratio = 0.13, 95% CI 0.01-0.84, p = 0.046; multivariable logistic regression) and faster rate of corneal healing (median: 17 days vs. 32 days; p = 0.029; unadjusted Kaplan-Meier analysis). Conclusion:PA keratitis remains a significant cause of ocular morbidity in the United Kingdom. CL-related disease shows distinct clinical features and better outcomes likely due to lower presenting disease severity and timely management of the disease.

Pre-Descemet’s endothelial keratoplasty (PDEK) is an evolving endothelial keratoplasty (EK) procedure that merges the advantages of Descemet membrane endothelial keratoplasty (DMEK) and ultrathin EK methods. This review reports the latest anatomical, surgical, and clinical research on PDEK and discusses its potential future role in current EK practices. Anatomical data show that the Pre-Descemet/Dua’s Layer (PDL/DL) acts as a biomechanical support, or “splint,” for Descemet’s Membrane (DM). This support facilitates the creation of grafts that are less tight and easier to handle compared to DMEK tissue. Notably, PDEK leads to rapid visual recovery and improvements in best-corrected visual acuity after surgery. Since PDEK results in an acceptable level of endothelial cell loss and has demonstrated reasonable detachment and rebubbling rates in published series, particularly in experienced hands, it is regarded as a reliable method for effectively utilising young and paediatric corneas, thereby optimising tissue use in eye bank procedures. Furthermore, advancements in surgical techniques, such as specialised PDEK clamps, an air-pump-assisted method, consistent 360-degree scoring, and the integration of optical coherence tomography into the surgical microscope, have resulted in higher success rates in creating Type 1 big-bubble, decreased overall tissue loss, and enhanced procedural consistency. Finally, PDEK merges the optical advantages of DMEK with enhanced intraoperative control and expanded donor options with the inclusion of young donor eyes, and is likely to gain wider adoption when integrated into training programs and eye bank protocols.

BackgroundAssessment and management of dry eye disease (DED) in the UK is increasingly taking place outside of specialist ophthalmology settings. While comprehensive, evidence-based international guidance exists, much of it does not reflect the realities of practice in the UK. A panel of experts was brought together to identify areas of consensus on assessment, management, and appropriate referral of DED in the UK National Health Service (NHS).MethodsA questionnaire was circulated to a panel consisting of 15 optometrists, ophthalmologists, and corneal specialists with experience and expertise in DED. Based on their responses, consensus statements were developed and underwent two rounds of voting, in which respondents indicated to what extent they agreed with each statement. A core steering panel of seven experts discussed the results and provided further context for the statements.ResultsStrong or very strong consensus was reached for 57/62 statements. Statements with very strong consensus included guidance on the minimum symptoms and signs to be assessed on initial presentation and simple guidance for grading the severity of the disease. Statements regarding initial treatment were divided by setting (primary and secondary care), and a strong or very strong consensus was reached on 17/20 statements relating to treatment options in these settings. Statements specific to referral included approximate target timelines, where possible, as well as guidance on key supporting information to help improve the efficiency of patient care.ConclusionsThis consensus provides a UK-focused resource to support consistent and effective care for patients with DED within the NHS.

IntroductionSmall incision lenticule extraction (SMILE)-derived lenticules have been repurposed as biocompatible scaffolds to incorporate and release therapeutic substances for ocular therapeutics. We aim to investigate the in vitro and in vivo release profiles of recombinant human nerve growth factor (rhNGF) from bioengineered human stromal lenticules prepared with microparticles incorporated with rhNGF (rhNGF-MPs) for up to 1 and 4 weeks, respectively.MethodsUpon bioengineered lenticule implantation, slit lamp, Anterior Segment Optical Coherence Tomography, and In Vivo Confocal Microscopy were performed to assess corneal biocompatibility, central corneal thickness (CCT), corneal nerve -fiber density (CNFD), -branch density, and -fiber length. Rabbit cornea, tears and aqueous humour were collected to quantify rhNGF release in vivo.ResultsA rapid in vitro release of rhNGF was detected until day 2, and with sustained release over 7 days. The pattern remains comparable even with the presence of antibiotic-antimycotic, trypan blue or fluorescein. Throughout the in vivo follow-up, no signs of corneal haze, edema, infiltration, or pathological increase in CCT were observed. A significant increase in CNFD (p = 0.001) at week 4 was reported in rhNGF-MPs than in Blank-MPs group. Finally, significantly higher NGF content in rabbit cornea and tear was found in rhNGF-MPs group compared to the endogenous NC group (p = 0.035 and p = 0.043, respectively).DiscussionBioengineered lenticules exhibit sustained rhNGF release for at least 7 days in vitro and up to 1 month in vivo. These results, together with absence of adverse effects, and significant increase in CNFD at 4 weeks after lenticule implantation suggest its promising potential for clinical use.

BackgroundThe pre-Descemet layer (Dua’s layer) (PDL/DL) and the Descemet membrane (DM) have the highest expression of elastin in normal corneas. Reduced expression of elastin occurs in the corneal stroma of patients with keratoconus (KC). This study aimed to examine the expression of elastin and that of other extracellular matrix (ECM) components, and proteoglycan proteins in the PDL/DL and DM in advanced KC.MethodsCorneal tissue obtained from four subjects with KC who underwent penetrating keratoplasty was compared with tissue from four normal corneas. The tissues were sectioned and analyzed with specific markers for extracellular matrix proteins and proteoglycans—namely, elastin, collagens I, IV, and VI, fibulin-2, and decorin—using immunohistochemical analysis. Fluorescence intensity was measured using ImageJ software and compared to controls.ResultsThe expression of elastin was significantly reduced in the PDL/DL and DM in KC cases compared to controls. Concurrently, an increased expression of elastin was noted anteriorly in the subepithelial region. Expression of collagen IV, collagen VI, and decorin was reduced in the PDL/DL and DM, whereas expression of collagen I and fibulin-2 was unaltered in KC cases compared to controls.ConclusionThe significant reduction of elastin in the PDL/DL and DM in cases of advanced keratoconus with acute corneal hydrops (ACH) may play a crucial role in the pathology of KC and the subsequent onset of ACH. Furthermore, elastin is considered to be pivotal in the disease progression, as keratoconus typically starts with a posterior elevation affecting these two layers.

PURPOSE:The wound healing process in the graft-host junction (GHJ) after deep anterior lamellar keratoplasty (DALK) can affect the outcome. We studied the anterior segment optical coherence tomography (OCT) features of the GHJ in the early and late postoperative stages. METHODS:OCT scans for 45 eyes of 43 patients within 4 weeks of DALK between 2014 and 2023 were retrospectively examined. Sixteen of these had a second scan 2 years or later postsurgery. GHJ profile, thickness, suture tracks, alignment (steps and shelves), and epithelial changes were examined and compared between early and late scans. RESULTS:The GHJ profile at 2 to 4 weeks postoperative was perpendicular (7 eyes, 43.7%), zigzag (4 eyes), C shaped (4 eyes), or mixed (1 eye). These profiles were persistent in most of the eyes (13 eyes, 81.2%) in the late scans. The thickest region was predominantly in the graft (13 eyes, 81.2%). This disparity disappeared in the late scans. Suture tracks were seen as hyper-reflective lines which remained visible in the late scans even after suture removal. Five eyes (31.2%) had anterior and 1 eye (0.6%) had posterior graft steps which disappeared in the late scans. Host shelves were seen in 43.3% in the first scan, and all of them had disappeared or became attenuated in the late scan. CONCLUSIONS:These findings can help surgeons assess their technique to reduce misalignment which could influence the outcomes and improve the understanding of the effect of the wound healing process in the GHJ.

To assess the spectrum of organisms causing microbial keratitis and their in-vitro anti-microbial sensitivities out of 2 hospitals in the East Midlands Region of the United Kingdom. A retrospective review was undertaken of all patients who underwent corneal scrapes for infectious keratitis between 2011 and 2021 at Royal Derby Hospital (RDH) in Derby and between 2009 and 2021 at King’s Mill Hospital in Mansfield. In total, the results of 645 corneal scrapes (from 622 patients) were analysed after exclusions. Of these, 307 (47.6

Anterior segment optical Coherence Tomography (AS-OCT) is used extensively in imaging the cornea in health and disease. Our objective was to analyse and monitor corneal vascularisation (CVas) through the corresponding back-shadows visible on AS-OCT. AS-OCT scans were obtained from 26 consecutive patients (eyes) with CVas of different aetiologies. AS-OCT horizontal line scans showing the back shadows cast by the vessels were analysed and correlated with findings seen on slit lamp examination. Vessels were graded clinically as active, partially regressed, and regressed. The density of back shadow in the patient samples before and after treatment was analysed using Image-J software. AS-OCT demonstrated a dense back shadow in all the 26 active vessels studied. When multiple vessels were present, the barcode sign was apparent. The back shadows absent in 22 (84.62

Purpose: Anterior segment optical coherence tomography (AS-OCT) is increasingly being used to complement slit-lamp biomicroscopy in the evaluation of corneal infections. Our purpose was to analyze, compare, and correlate the clinical signs elicited by these 2 methods in patients with infectious keratitis (IK). Methods: Slit-lamp photomicrographs (diffuse and slit beam) and AS-OCT scans were obtained from 20 consecutive patients (21 eyes) with IK. AS-OCT horizontal line scans representing the top, middle, and bottom of the lesions were analyzed and compared with findings seen on slit-lamp photographs. Epithelial defects, thickness, irregularity; presence of infiltrate and its depth; corneal edema or melting; vascularization; Descemet membrane detachment; and presence of keratic precipitates were analyzed with both imaging techniques. AS-OCT features included hyperreflectivity, hyporeflectivity, shadowing, and tissue morphology. Statistical analysis was performed using GraphPad Prism 8.2.1. Results: AS-OCT was significantly more likely to detect corneal thickening (P < 0.001), epithelial hyperplasia (P = 0.027), infiltrate depth (P < 0.001), presence of inflammatory plaque (P = 0.0002), DM-endothelial complex undulations (P < 0.001), keratic precipitates (P = 0.0006), and Descemet membrane detachment (0.000), than slit-lamp imaging. Conclusions: AS-OCT can be a helpful adjunctive test in the evaluation of patients with IK. AS-OCT complements slit-lamp biomicroscopy and photography in the diagnosis and monitoring of IK and may serve an important role in telemedicine compared with slit-lamp photography alone.

ABSTRACT:An integrated cell, tissue, and eye bank is vital to meet the evolving needs of ocular transplant therapies. In addition to traditional corneal transplant tissues, it encompasses processing and delivery of transplant materials for newer treatments like cell-based therapies and gene-modified products, adhering to rigorous standards, optimizing tissue utilization with comprehensive services for surgeons.

Neurotrophic Keratopathy (NK) is not a specific disease entity but a consequence of several conditions with varied aetiopathogenesis, of which a loss or reduction in corneal sensitivity is the hallmark. NK is clinically graded as Mild (stage1), Moderate (stage 2) and Severe (stage 3). The grading helps in understanding severity and planning treatment. Management can be considered in two parts. The first is the management of the underlying condition when active, for example herpes virus keratitis, bacterial ulcers and immune mediated ulcerative keratitis; and the second part, which deals with treatment of the non‐healing epithelial defect, stromal melting with or without vascularization and perforation that remains due to epithelial, stromal and corneal nerve pathology. Management of mild and moderate NK begins with the identification and elimination of any obvious underlying cause such as neuroleptic, antipsychotic, antihistamine and other systemic medications, preservatives in long term topical medications; and treatment of concurrent ocular surface infection. Tear substitutes and anti‐inflammatory agents both steroids and specific immunosuppressors like cyclosporin and lifitegrast should be used early. Antibiotics can be used prophylactically or to treat subclinical or overt infection. Medication with preservatives should be avoided. Prevention of progression to severe (stage 3) NK can be achieved with antiproteases such as citrate, tetracyclines and macrolides. Substrate re‐generating agents like Cacicol and promoters of epithelial regeneration like co‐enzyme Q10 target aspects of the underlying pathology. The introduction of recombinant human nerve growth factor (rh)NGF (Cenegermin/Oxervate) has provided specific therapy that addresses the basic defect related to corneal nerves. Insulin drops are proving to be useful and amniotic membrane extracts/amniotic fluid has also been tried. Autologous and pooled allo serum or plasma drops, which provide a variety of known and unknown factors have also proved useful but may at times aggravate the condition. Usually a combination of two or more of the above are required but rhNGF and insulin hold considerable promise for long term remission. Medical treatment is often augmented with non‐surgical interventions such as bandage contact lens, padding, punctal plugs, botulinum toxin, frost suture and glue. These are primarily designed to deal with exposure, dry eyes and reduce the abrasive effect of lid blinks, to promote healing. Useful surgical procedures include tarsorrhaphy, amniotic and conjunctival grafts, penetrating and lamellar keratoplasty and limbal stem cell transplants. Surgical interventions are designed to augment effects of the non‐surgical interventions, reduce scarring, deal with complications and restore sight. A key principle is that wound healing after any form of surgery or transplant, is poor if the corneal sensations remain impaired or absent.

BACKGROUND/OBJECTIVES:To examine the clinical characteristics, risk factors and outcomes of contact lens-related bacterial keratitis (CLBK) in a large UK tertiary referral centre. SUBJECTS/METHODS:A retrospective analysis of all patients who presented to the Queen's Medical Centre, Nottingham, UK, with suspected CLBK between October 2015 to September 2022 (a 7-year period) was performed. Relevant data on demographic factors, CL wear behaviour, causes, clinical characteristics, and outcomes were analysed. RESULTS:We included 138 patients with CLBK; the mean age was 42.0 ± 17.8 years and 74 (53.6%) patients were male. Most CLBK were related to soft CL wear (94.5%), particularly monthly disposable (42.5%) and daily disposable (24.4%) CLs. Poor CL wear behaviour/hygiene was documented in 57.1% cases. Among the 64 (46.4%) microbiological-positive cases (n = 73 organisms), Pseudomonas aeruginosa (36, 49.3%) and Staphylococcus spp. (16, 21.9%) were most commonly identified. Six (4.3%) cases were polymicrobial. Most (97.0%) patients were successfully treated with topical antibiotics alone, with 80.6% achieving good final corrected-distance-visual-acuity (CDVA) of ≥ 0.30 logMAR. Poor visual outcome (final CDVA < 0.30 logMAR) was significantly associated with presenting CDVA < 0.6 logMAR (p = 0.002) and central ulcer (p = 0.004). Poor corneal healing (complete healing of > 30 days from initial presentation) was significantly associated with age > 50 years (p = 0.028), female gender (p = 0.020), and infiltrate size >3 mm (p = 0.031). CONCLUSIONS:Poor CL wear behaviour/hygiene is commonly observed in CLBK, highlighting the importance of improved counselling and awareness regarding CL use and hygiene. When presented early and managed appropriately, most patients are able to achieve good clinical outcomes with medical treatment alone.

Background To compare the diagnostic performance of microbiological culture and 16S/18S rRNA gene polymerase chain reaction (PCR)-Sanger sequencing for infectious keratitis (IK) and to analyse the effect of clinical disease severity on test performance and inter-test concordance.Methods This was a three-arm, diagnostic cross-sectional study. We included all eligible patients who presented with presumed bacterial/fungal keratitis to the Queen's Medical Centre, Nottingham, UK, between June 2021 and September 2022. All patients underwent simultaneous culture (either direct or indirect culture, or both) and 16S (pan-bacterial)/18S (pan-fungal) ribosomal RNA (rRNA) PCR-Sanger sequencing. The bacterial/fungal genus and species identified on culture were confirmed using matrix-assisted laser desorption/ionization-time-of-flight mass spectrometry. Relevant clinical data were also collected to analyze for any potential clinico-microbiological correlation. Main outcome measures included the diagnostic yield, test accuracy (including sensitivity and specificity), and inter-test agreement [including percent agreement and Cohen's kappa (k)].Results A total of 81 patients (86 episodes of IK) were included in this study. All organisms identified were of bacterial origin. Diagnostic yields were similar among direct culture (52.3%), indirect culture (50.8%), and PCR (43.1%; p = 0.13). The addition of PCR enabled a positive diagnostic yield in 3 (9.7%) direct culture-negative cases. Based on composite reference standard, direct culture had the highest sensitivity (87.5%; 95% CI, 72.4-95.3%), followed by indirect culture (85.4%; 95% CI, 71.6-93.5%) and PCR (73.5%; 95% CI, 59.0-84.6%), with 100% specificity noted in all tests. Pairwise comparisons showed substantial agreement among the three tests (percent agreement = 81.8-86.2%, Cohen's k = 0.67-0.72). Clinico-microbiological correlation demonstrated higher culture-PCR concordance in cases with greater infection severity.Conclusions This study highlights a similar diagnostic performance of direct culture, indirect culture and 16S rRNA PCR for bacterial keratitis, with substantial inter-test concordance. PCR serves as a useful diagnostic adjuvant to culture, particularly in culture-negative cases or those with lesser disease severity (where culture-PCR concordance is lower).