Evidence regarding suppressive valacyclovir treatment on postherpetic neuralgia is necessary to guide care. To test the hypothesis that suppressive treatment with 1000 mg/d of oral valacyclovir for 12 months reduces the prevalence, severity, and duration of postherpetic neuralgia compared with placebo at 12 and 18 months in participants with herpes zoster ophthalmicus (HZO). Multicenter, placebo-controlled randomized clinical trial including 527 immunocompetent, nonpregnant adults with history of HZO rash, documented keratitis, or iritis within 1 year and an estimated glomerular filtration rate of 45 mL/min/1.73 m2 or greater. The study was conducted at 95 participating sites (in Canada, New Zealand, and the US) from November 2017 to June 2024 and participant visits occurred every 3 months. Treatment with 1000 mg/d of valacyclovir or placebo for 12 months. Prevalence of postherpetic neuralgia, severity as determined by pain score (a score of ≥3 on a scale of 1-10), pain duration (≥3 months after HZO onset), and total daily dose of pain medication. Of the 527 participants (490 completed 12 months of treatment and 460 completed 18 months), 73 (14%) had postherpetic neuralgia and were analyzed by age at HZO onset (<60 years or ≥60 years) and disease duration (recent [<6 months] or chronic [≥6 months]). Of the 73 participants with postherpetic neuralgia (34 in the valacyclovir group and 39 in the placebo group), the mean age was 62.4 years (SD, 13.6 years), 59% were female, 5% were Black or African American, and 10% were Hispanic. The prevalence of postherpetic neuralgia at 12 months was not reduced by valacyclovir (12/32 [38%]) compared with placebo (14/35 [40%]) (between-group difference, 2.5% [95% CI, −20.8% to 25.8%]; P>.99). The participants who were younger than 60 years at HZO onset and had a chronic disease duration had lower pain scores in the valacyclovir group (mean score, 0.3 [SD, 0.9]) vs the placebo group (mean score, 0.8 [SD, 1.9]) at 12 months (P = .045) and at 18 months (mean score, 0.2 [SD, 0.9] vs 1.0 [SD, 2.3], respectively; P = .02). There was a decrease in pain duration in the valacyclovir group at 18 months (mean, 13.6 [SD, 11.4] months) vs the placebo group (mean, 18.7 [SD, 29.5] months) (linear mixed-effects model between-group difference, −3.39 months [95% CI, −6.73 to −0.04 months]; P = .046). The total daily dose of neuropathic pain medication was lower in the valacyclovir group (mean, 271.4 [SD, 593.8] mg/d) vs the placebo group (mean, 363.4 [SD, 592.2] mg/d) at 12 months (linear mixed-effects model P = .006) and at 18 months (mean, 209.0 [SD, 412.8] mg/d vs 286.2 [SD, 577.9] mg/d, respectively; linear mixed-effects model P = .01). One year of suppressive treatment with valacyclovir was associated with a lower dosage of neuropathic pain medication. Participants in the valacyclovir group, who were younger at HZO onset and had a chronic disease duration, had lower pain scores. These secondary outcomes support consideration of 1 year of suppressive treatment with valacyclovir to reduce dosage of pain medications and pain due to HZO. ClinicalTrials.gov Identifier: NCT03134196

High-quality evidence regarding suppressive valacyclovir treatment in herpes zoster ophthalmicus (HZO) is necessary to guide care. To determine whether suppressive valacyclovir compared with placebo delays the occurrence of new or worsening stromal keratitis (SK), endothelial keratitis (EK), iritis, or dendriform epithelial keratitis (DEK) during 12 months of treatment and if treatment benefit persisted at 18 months (secondary end point). The Zoster Eye Disease Study (ZEDS) was a randomized clinical trial conducted in 95 sites from November 2017 to June 2024. Immunocompetent, nonpregnant adults with a history of an HZO rash, documented active keratitis or iritis within 1 year, and an estimated glomerular filtration rate of 45 mL/min/1.73 m2 or greater were eligible. After determined to be eligible, participants were randomized in 4 strata: age at onset (<60 years vs ≥60 years) and disease duration (<6 months vs ≥6 months). A total of 12 months of double-masked daily valacyclovir, 1000 mg, or placebo. The primary outcome was time to first occurrence within 12 months of new or worsening SK, EK, iritis, or DEK. A total of 527 participants (median [IQR] age, 60 [50-68] years; 266 female [50.5%]; 266 in the valacyclovir group; 261 in the placebo group) were randomized in 4 strata; 481 completed 12 months, and 460 completed 18 months. Data were analyzed by intention to treat. At 12 months, primary end points occurred in 86 participants (33%) assigned to placebo and 74 (28%) assigned to valacyclovir, and at 18 months in 104 participants (40%) assigned to placebo and 86 (32%) assigned to valacyclovir. The hazard ratio (HR) of the primary end point at 12 months was 0.77 for participants taking valacyclovir vs placebo (HR, 0.77; adjusted 95% CI, 0.56-1.05; P = .09) and 0.73 at the secondary end point at 18 months (HR, 0.73; adjusted 95% CI, 0.55-0.97; P = .03). There was a reduction of multiple other secondary end points at 12 months (HR, 0.70; 95% CI, 0.52-0.95; P = .02) and 18 months (HR, 0.72; 95% CI, 0.55-0.95; P = .02). Although the primary outcome did not show a benefit of suppressive valacyclovir treatment, secondary study outcomes showed treatment superiority at the 18-month end point and reduced number of multiple episodes of keratitis or iritis at both 12 and 18 months. These results support consideration of 1 year of suppressive valacyclovir treatment for HZO. ClinicalTrials.gov Identifier: NCT03134196

Purpose: To characterize recent socioeconomic trends in patients with keratoconus/corneal ectasias undergoing corneal crosslinking (CXL). Setting: A deidentified administrative medical claims database comprised commercial and Medicare Advantage health claims from across the United States. Design: Population-based retrospective cohort study. Methods: This study identified 552 patients with keratoconus/corneal ectasia who underwent CXL and 2723 matched controls who did not undergo CXL based on Current Procedural Terminology coding from a U.S. national insurance claims database from 2016 to 2020. For each patient, characteristics, including sex, race, age, household net worth, education level, insurance plan type, and geographic region, were extracted. Multivariate logistic regression was conducted to determine the odds of undergoing crosslinking. Results: Age 30 years or older (odds ratio [OR], 0.34, P < .001) was associated with decreased likelihood of undergoing CXL. Sex, race, education, and patient income were not associated with odds of undergoing CXL. Patients with health maintenance organization insurance had lower odds of undergoing CXL (OR, 0.64, P = .047). Geographically, patients on the east coast (OR, 0.37, P < .001) and Lower Midwest (OR, 0.31, P < .001) had statistically lower odds of undergoing crosslinking. Conclusions: This is the first study to identify socioeconomic determinants of CXL, and it highlights that geographic location and insurance type may limit accessibility to patients.

A 12 year-old male patient with a history of seasonal allergies presented for evaluation. Visual acuity was 20/20 in both eyes. There was bilateral lipid deposition along the superior 4 clock hours of both corneas without thinning but with mild vascularization and cysts [Fig. 1]. Topography did not reveal any thinning or steepening, ruling out Terrrien's marginal degeneration.[1] These findings are consistent with pseudogerontoxon, a condition that bears similarity to arcus senilis but is observed in individuals with a history of vernal or atopic keratoconjunctivitis.[2] Limbal vasopermeability from chronic inflammation leads to lipid deposition in the anterior stroma.[3] Although pseudogerontoxon is not visually significant, it may be mistaken for other corneal deposits and peripheral degenerations.Figure 1: Slit-lamp photography and pentacam topography of pseudogerontoxonDeclaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship: Nil. Conflicts of interest: There are no conflicts of interest.

In Vivo Microscopy, pp. 1-8 (2024) Free AccessChapter 1: Eye, AnteriorStephen E. Orlin and Daniel SareskyStephen E. OrlinScheie Eye Institute, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA and Daniel SareskyCornea & External Diseases Subspeciality, Cataract & Refractive Surgery, Comprehensive Ophthalmology, Visionary Eye Doctors, Rockville, MD, USAhttps://doi.org/10.1142/9789813206984_0001Cited by:0 (Source: Crossref) PreviousNext AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsRecommend to Library ShareShare onFacebookTwitterLinked InRedditEmail Abstract: In ophthalmology, advances in imaging have revolutionized the field both diagnostically and therapeutically. The development of these novel techniques has significantly improved our understanding of ocular anatomy and the application of this latest technology has availed millions of patients with vision-saving treatments that were unheard of just a few decades ago. FiguresReferencesRelatedDetails Recommended In Vivo MicroscopyMetrics History PDF download

Depositions and degenerative diseases of the cornea, sclera, and conjunctiva encompass a wide spectrum of pathologies. Degenerative diseases are common and usually result from physiologic changes related to aging, long-standing environmental insults, or systemic disease. Depositions typically are related to drug exposure or systemic illness. In this article, we review the clinical characteristics, pathophysiology, and treatment options of various depositions and degenerations of the conjunctiva, cornea, and sclera. Clinicians need to be able to recognize these conditions, as an appropriate ophthalmologic diagnosis may uncover an undiagnosed systemic disorder.

Background/objectives: Studies have reported an association between herpes zoster ophthalmicus (HZO) and stroke. We sought to validate this association with rigorous controls for both medical comorbidities and social factors using a nationwide U.S. administrative medical claims database. Subjects/methods: A two-step approach was taken: first a retrospective case-control study was performed, followed by a self-controlled case series (SCCS). For the case control study, cox proportional hazard regression with inverse proportional treatment weighting assessed the hazard for stroke. In the SCCS, incidence of stroke was compared prior to and after the diagnosis of HZO. Results: For the case-control study, 25,720 cases and 75,924 controls met our eligibility criteria. 1712 (6.7%) and 4544 (6.0%) strokes occurred in the case and control groups respectively, conferring an 18% increased risk of stroke in the observed 1-year post-HZO period (HR = 1.18, 95% CI: 1.12-1.25, p < 0.001). SCCS analysis showed the risk for stroke was highest in the month immediately after HZO episode compared to any other time range (1-30 days after, relative risk 1.58, p < 0.001) and even higher when assessing time more distal time points prior to the HZO diagnosis (days 1-30 after HZO diagnosis had RR = 1.69 (95% CI: 1.38-2.07) and RR = 1.93 (95% CI: 1.55-2.39) compared with days -120 to -91 and -150 to -121 prior to index, respectively (p < 0.001). Conclusions: After accounting for stroke risk factors, our analysis confirms the association between HZO and stroke, with highest risk in the immediate month after an episode.

Dry eye disease (DED) is a multifactorial disorder caused by abnormalities of the tear film that causes damage to the ocular surface. Screening tools are helpful in making the diagnosis and in determining disease severity. It is important to take a careful history and to evaluate meibomian gland physiology, tear film quality, meibomian gland status, and tear production. Clinicians should take a stepwise approach in treating DED. Treatments vary for evaporative dry eye, aqueous deficiency, and/or inflammatory DED. For patients with symptoms that have not improved following conservative measures, prescription medications, blood products, procedures or devices can be considered.

The most recent IC3D classification (2015) categorizes the corneal dystrophies based on genetic, clinical, and histologic characteristics. Here we review the classification of the corneal dystrophies as epithelial and subepithelial, epithelial-stromal TGFB1, stromal, and endothelial. We discuss the variety of available medical and surgical treatment modalities based on symptomatology and anatomic area of the cornea affected. We explore the recent advancements in the area of corneal regeneration without the use of donor grafts, including injection of cultured endothelial cells and gene therapy.

Current approaches to the surgical correction of aphakia include anterior chamber intraocular lenses (IOLs), iris-fixated IOLs, sulcus IOLs, and scleral-fixated IOLs with or without sutures. Anterior chamber and iris-fixated IOLs are technically easier to place but are associated with risks including corneal decompensation, uveitis, and glaucoma. Sulcus placement of IOLs can achieve physiologic positioning of the lens but requires adequate capsular support. Overall, current approaches to correction of aphakia have comparable efficacy and safety outcomes, and the advantages and disadvantages of each technique should be considered in light of patient and surgeon factors in surgical planning.

Purpose To determine whether signs and symptoms of ocular surface disease improve after placement of a self-retained, cryopreserved amniotic membrane (CAM) in patients with Sjögren syndrome (SS). Methods The medical records of SS patients who received a self-retained CAM implant (Prokera or Prokera Slim; TissueTech Inc, Doral, FL) for the treatment of ocular surface disease between August 2012 and August 2016 at a single, large academic institution were reviewed retrospectively. Visual acuity, results of slit-lamp examination of the cornea and conjunctiva, and dry eye symptoms, were evaluated before and after CAM insertion. Results A total of 6 eyes of 6 patients (all female; mean age, 62.5 ± 13.0 years [range, 49-86 years]) were included. All patients were on topical medications at the time of the study and had signs of ocular surface dryness. There were reductions in corneal and/or conjunctival staining in 5 eyes (83%) after the CAM dissolved. All patients who completed therapy (5/5) experienced a relapse in their signs and symptoms within 1 month of removal of the CAM, with an average time to relapse of 24.6 days. Mean follow-up time was 54.5 days. Foreign body sensation and blurred vision were the most common complaints associated with the CAM implant. Conclusions In this small case series, self-retained CAM implantation was found to be beneficial in SS patients with ocular surface disease that is refractory to standard therapies; however, we found that the effects were temporary. Future larger studies are needed to confirm these benefits.

Objective: To survey ophthalmologists about current practice patterns regarding the evaluation of dry eye patients and referrals for a Sjogren syndrome (SS) workup. Methods: An online survey was sent to ophthalmologists affiliated with the Scheie Eye Institute or Wills Eye Hospital using REDCap in August 2015. Descriptive statistics were used to summarize the data. Results: Four hundred seventy-four survey invitations were sent out and 101 (21%) ophthalmologists completed the survey. The common traditional dry eye test performed was corneal fluorescein staining (62%) and the most common newer dry eye test performed was tear osmolarity (18%). Half of respondents (51%) refer fewer than 5% of their dry eye patients for SS workups, with 18% reporting that they never refer any patients. The most common reasons for referrals included positive review of systems (60%), severe dry eye symptoms (51%) or ocular signs (47%), or dry eye that is refractory to treatment (42%). The majority (83%) felt that there is a need for an evidence-based standardized screening tool for dry eye patients to decide who should be referred for evaluation for SS. Conclusions: Ophthalmologists continue to prefer the use of traditional dry eye tests in practice, with the most common test being corneal fluorescein staining. There is an underreferral of dry eye patients for SS workups, which is contributing to the continued underdiagnosis of the disease. Most respondents felt that there was a need for an evidence-based standardized screening tool to decide which dry eye patients should be referred for SS evaluations.

Purpose: To report a case of bilateral Urrets-Zavalia syndrome (UZS) after Descemet stripping automated endothelial keratoplasty (DSAEK).Methods: Case report.Results: A 61-year-old patient with Fuchs endothelial dystrophy initially developed UZS in the left eye after DSAEK. Thirteen months later, she underwent combined cataract surgery and DSAEK in the right eye, and postoperatively she was noted to have elevated intraocular pressure and a fixed and dilated pupil on the first postoperative day. Both pupils showed partial improvement in reactivity over the course of weeks to months. This is the first case of bilateral UZS after DSAEK surgery and in a patient with Fuchs dystrophy.Conclusions: UZS may occur bilaterally after DSAEK. Because elevated intraocular pressure has been shown to be a risk factor for this condition, this should be monitored closely during the postoperative period.

A 79-year-old female with a 2-month history of newly diagnosed myelodysplastic syndrome for which she received blood transfusion with darbepoetin alfa presented with bilateral anterior uveitis 1 day after her fourth transfusion. On exam, visual acuity was 20/20 in both eyes with biomicroscopy notable for conjunctival injection and anterior chamber cell and flare consistent with anterior uveitis. She had no systemic symptoms, no history of eye trauma, and no known infections. This case, along with prior reports in the literature, suggests that anterior uveitis may be an idiosyncratic complication of darbepoetin alfa therapy.

PURPOSE:To report a case of ocular surface squamous neoplasia (OSSN) that resolved with topical Aloe vera eye drop treatment.METHODS:A 64-year-old Hispanic woman with a lesion typical for OSSN in her left eye was followed up with multiple clinical examinations and ocular surface photographs to document changes over time with A. vera-based topical treatment.RESULTS:The patient refused biopsy of her lesion and traditional treatments and, instead, initiated using A. vera eye drops 3 times daily. At follow-up visits, the lesion was noted to regress until it finally resolved 3 months after commencing treatment. No additional topical medications were used, and she has remained tumor free for 6 years.CONCLUSIONS:Ongoing research is warranted because A. vera may represent a new therapeutic class of medications for OSSN treatment.