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   Table of Contents - Current issue
January-March 2022
Volume 36 | Issue 1
Page Nos. 1-121

Online since Monday, July 11, 2022

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A need to maximize updates on detecting keratoconus Highly accessed article p. 1
Samar A Al-Swailem
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Keratoconus epidemiology: A review Highly accessed article p. 3
José A P. Gomes, Pablo F Rodrigues, Luiz L Lamazales
Keratoconus is an ectatic corneal disease that affects both men and women, usually at a young age. Risk factors such as eye rubbing, environmental and genetic factors contribute to its pathogenesis. Keratoconus presents a variable prevalence, being as high as 5% of the population in the Middle East. In this review, an English-language search for keratoconus epidemiology was undertaken using the PubMed database. We present and discuss the findings of the most relevant epidemiological studies on keratoconus and describe its characteristics and risk factors, correlating them with its pathogenesis.
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Biochemical and molecular alterations and potential clinical applications of biomarkers in keratoconus Highly accessed article p. 7
Vaitheeswaran Ganesan Lalgudi, Rohit Shetty, Kanwal Ken Nischal, Setareh Ziai, Mona Koaik, Swaminathan Sethu
Keratoconus (KC) is a complex multifactorial corneal ectatic disorder, with disease onset commonly in the second-third decades significantly affecting quantity, quality of vision, and quality of life. Several pathways and factors such as eye rubbing, inflammatory, oxidative, metabolic, genetic, and hormonal among others have been studied in the last two decades. However, the management of KC is still based on a few “one-size fits all” approaches and is predominantly guided by topo/tomographic parameters. Consideration of the several novel factors which have the potential to be biomarkers in addressing several unanswered questions in the disease process could help in the better predictive ability of progression or vision loss and customization of treatment options. This article delves into the understanding of these novel factors or biomarkers based on the pathogenesis of KC and features a special focus on their potential clinical applications and their future role in personalized medicine.
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Corneal biomechanics for corneal ectasia: Update p. 17
Louise P G. Esporcatte, Marcella Q Salomão, Nelson S Junior, Aydano P Machado, Érica Ferreira, Tomás Loureiro, Renato A Junior
Knowledge of biomechanical principles has been applied in several clinical conditions, including correcting intraocular pressure measurements, planning and following corneal treatments, and even allowing an enhanced ectasia risk evaluation in refractive procedures. The investigation of corneal biomechanics in keratoconus (KC) and other ectatic diseases takes place in several steps, including screening ectasia susceptibility, the diagnostic confirmation and staging of the disease, and also clinical characterization. More recently, investigators have found that the integration of biomechanical and tomographic data through artificial intelligence algorithms helps to elucidate the etiology of KC and ectatic corneal diseases, which may open the door for individualized or personalized medical treatments in the near future. The aim of this article is to provide an update on corneal biomechanics in the screening, diagnosis, staging, prognosis, and treatment of KC.
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Applications of epithelial thickness mapping in corneal refractive surgery p. 25
Dan Z Reinstein, Timothy J Archer, Ryan S Vida
In this review, we discuss the applications of epithelial thickness mapping in corneal refractive surgery. The review describes that the epithelial thickness profile is nonuniform in the normal eye, being thinner superiorly than inferiorly and thinner temporally than nasally. It is postulated that this is due to the eyelid forces and blinking action on the superior cornea. Changes in the epithelial thickness profile have been found to be highly predictable, responding to compensate for changes in the stromal curvature gradient, using the eyelid as an outer template. This leads to characteristic changes in the epithelial thickness profile that can be used for early screening in keratoconus, postoperative monitoring for early signs of corneal ectasia, and for determining whether further steepening can be performed without the risk of apical syndrome following primary hyperopic treatment. Compensatory epithelial thickness changes are also a critical part of diagnosis in irregular astigmatism as these partially mask the stromal surface irregularities. The epithelial thickness map can then be used to plan a trans-epithelial photorefractive keratectomy treatment for cases of irregularly irregular astigmatism.
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Deep anterior lamellar keratoplasty for keratoconus: Elements for success p. 36
Marco Pellegrini, Angeli Christy Yu, Massimo Busin
Advanced keratoconus may require keratoplasty when the patient can no longer achieve functional vision with glasses and contact lenses. Deep anterior lamellar keratoplasty (DALK) has become the surgical treatment of choice due to its undisputed advantages over penetrating keratoplasty including the reduced risk of intraoperative complications, the absence of endothelial immune rejection, and the longer graft survival. Albeit “big-bubble” DALK still represents the most popular surgical method, several modifications have been developed over the years. This allowed standardization of the technique, with improved success rates and clinical outcomes. This review presents an overview on the literature on DALK surgery for keratoconus. We discuss state-of-the art surgical techniques, current evidence on the clinical outcomes and complications as well as possible future directions.
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Demographic and clinical variations of keratoconus in Saudi population p. 42
Nasser A Al Qahtani, Mohammad O Abahussin, Abdullah A Assiri
PURPOSE: The aim of this prospective study was to identify the demographic and clinical variations of keratoconus (KC) in Saudi Arabia. METHODS: A self-administered survey was completed by patients in Saudi hospitals. The survey included questions on demographics, educational level, treatment options, dry eye, eye rubbing because of allergy, residence, family history, and consanguineous marriage. RESULTS: Six hundred and forty-eight patients (375 – male, 273 – female; mean age: 26.89 [standard deviation: 7.04] years; range: 11–50 years) were conducted at 13 central hospitals in all 13 administrate areas of Saudi Arabia over a 1-year period. Five hundred and forty-three (83.8%) patients had a secondary school diploma or diploma's degree of education and mostly were from the Aseer and Riyadh regions. The geographical distribution rate of KC was highest in the mountainous areas. For dry eye, 21.9% and 44.8% of the patients, respectively, reported frequent or occasional dryness and 13.4% and 48.9% of the patients, respectively, reported frequent or occasional bouts of eye allergy. Furthermore, 17.9% and 61.9% of the patients, respectively, reported that they constantly or sometimes rubbed their eyes. Marriages were endogamous in 53.5% of the patients and the family history was positive by 56.8%. There was a history of ocular disease in 27% of the patients and the systemic disease was 13%. CONCLUSION: This study is the first to describe the regional demographic and clinical variations of KC in Saudi Arabia. Its findings suggest that the different distribution of keratoconic patients between provinces is attributable to genetic and/or environmental factors.
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Accelerated versus conventional corneal collagen crosslinking: Short-term clinical outcomes in stabilizing keratoconus p. 47
Walaa Aldairi, Reham AlQahtani, Salem Alzaid, Ahmed Mousa, Rajiv Khandekar, Samar A Al-Swailem
PURPOSE: The purpose of the study is to compare the short-term outcomes of corneal collagen crosslinking (CXL) using the conventional (Dresden) protocol and an accelerated CXL (ACXL) protocol to stop keratoconus (KC) progression. METHODS: A chart review was performed for all the patients with KC who underwent CXL in the last 7 years. Data were compared at baseline and at all follow-up examinations for uncorrected visual acuity (UCVA), best spectacle corrected visual acuity (BCVA), keratometry (K), central corneal thickness, and complications of CXL. Pre- and post-intervention values were compared for each group. P < 0.05 was statistically significant. RESULTS: After the treatment, there was a statistically greater improvement in UCVA in the conventional CXL (CCXL) group (49%) compared to the ACXL group (34%) (P = 0.028). The improvement in BCVA was similar between the groups (P = 0.060). Gain of two lines of UCVA and stability were comparable between groups (P = 0.078 and P = 0.060, respectively). The average flat K and steep K values fluctuated remarkably across different follow-up assessments in both the groups. At 3 months of follow-up, there was a statistically significantly faster return to baseline levels of flat and steep Ks in the CCXL group (P = 0.028 and P = 0.002, respectively). CONCLUSION: The findings of the current study confirm the efficacy and safety of accelerated high-fluence CXL compared to CCXL. Both protocols were effective in stabilizing KC at 9th-month and the last follow-up visit. Larger prospective randomized controlled trials and longer follow-up are required to confirm our findings.
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Combined corneal wavefront-guided transepithelial photorefractive keratectomy and accelerated corneal collagen cross-linking following intracorneal ring segment implantation in management of moderate keratoconus p. 53
Ashraf M Bakhsh, Shaaban A M. Elwan, Tamer M El-Atris, Abdulrahman M Al-Salowle, Mazen S Alsamnan
PURPOSE: Keratoconus (KC) leads to gradual progressive loss of vision in young and adult patients. For the purpose of visual rehabilitation and for hindering KC progression in patients, we designed this study. The main aim of this study is to help the KC patients to improve and stabilize their vision. METHODS: This prospective consecutive uncontrolled study includes 36 eyes of 36 patients with moderate degree of KC. All patients underwent combined wavefront-guided transepithelial photorefractive keratectomy (TPRK) and accelerated corneal collagen cross-linking (ACXL) after intracorneal ring segment (ICRS) implantation. Different measures will be evaluated at baseline, after ICRS implantation, and at one, 3, 6, and 12 months after combined (TPRK and ACXL). These measurements are uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), manifest refraction spherical equivalent (MRSE), corneal indices based on Scheimpflug tomography, and higher-order aberrations (HOAs) based on (Sirius, Schwind) tomography. RESULTS: There were significant improvements in logMAR (UDVA and CDVA) and reduction in sphere, manifest cylinder, MRSE, maximal keratometry, and mean keratometry after ICRS implantation in the first stage. After TPRK and ACXL as the second stage, there were significant improvements in visual acuity of both logMAR UDVA and CDVA. Reduction in refractive outcomes, including MRSE, sphere, and manifest cylinder. All corneal indices including steep, flat, mean, and maximal keratometries had been decreased. Furthermore, there were significant improvements in the final root mean square, HOAs, and coma aberrations from baseline. CONCLUSION: In moderate KC, triple therapy of ICRS implantation followed by combined TPRK and ACXL appears to be a safe and effective approach. This approach provides an improvement in visual acuity, refraction, corneal indices, and HOAs. These improvements were maintained for 1 year postoperatively. It also halts KC progression.
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Long-term outcomes and causes of intrastromal corneal ring segment explantation in a tertiary eye hospital p. 64
Hussain F Al-Habboubi, Hernan Martinez-Osorio, Azza M Y. Maktabi, Abdulrahman H Badawi, Faisal N Aldosari, Rajiv Khandekar, Samar A Al-Swailem
PURPOSE: To evaluate the causes and long-term outcomes after intrastromal corneal ring segment (ICRS) explantation in the King Khaled Eye Specialist Hospital. METHODS: This was retrospective cohort study. Two groups were analyzed: Group one, ICRS surgery done in our hospital (n = 41) and group two, surgery done outside but removed in our hospital (n = 29). Causes and postoperative management after ICRS removal were analyzed. For statistical analysis, groups were analyzed into two subgroups of causes of ICRS removal: Visual disturbance versus extrusion/infection/neovascularization (NV) subgroups; and two subgroups of postoperative treatment: Corneal transplant (CT) versus Contact lens (CL)/eyeglasses subgroups. RESULTS: The most common cause of ICRS removal in group one was visual disturbance (45.2%) while in group two was extrusion (41.2%). CL is the preferable management after explantation. 76% of ICRS removal occurred during the first 4 years. In group 1, there was significant worse preimplantation visual acuity (P = 0.02) in CT subgroup versus CL/eyeglasses. CT subgroup had lower pachymetry of 437.4 μm (P = 0.04) and higher myopia of 8.05 (P = 0.03) than CL/eyeglasses subgroup. For group two, there was a significant improvement in uncorrected visual acuity in visual disturbances subgroup after explantation (P = 0.004). After explantation, visual disturbances subgroup had higher myopia -4.4 than extrusion subgroup -1.15 (P = 0.004). CONCLUSION: Seventy-six percent of ICRS removal occurred during the first 4 years. High myopia and pachymetry lower than 437 um were associated with visual disturbances and further management with corneal transplantation. High myopia was also associated with visual disturbances in surgeries done outside our hospital.
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Prevalence of refractive errors in school-going children of Taif region of Saudi Arabia p. 70
Talal A AlThomali, Majed AlQurashi, Abdulhamid S AlGhamdi, Afra Ibrahim, Farhan K AlSwailmi
PURPOSE: To determine the prevalence of refractive errors in the pediatric population in Taif, Saudi Arabia. METHODS: This cross-sectional study included 7356 eyes of 3678 primary and secondary school children (males = 1837; females = 1841) with a mean age of 11.8 ± 2.2 years (range: 7–18) (males = 11.4 ± 2.0 [range: 8–16]; females = 12.2 ± 2.3 [range: 7–18]). All participants were selected from the school registers. The participants underwent noncycloplegic refraction to determine refractive errors. Students who refused visual acuity assessment or eye examination and were inconsistent in visual acuity assessment were excluded. RESULTS: The manifest refraction spherical equivalent of the study population was 0.37 ± 1.52 D (range from − 18.4 to 8.8 D) (males = −0.32 ± 1.4 D [range − 15.88–8.8 D]; females = −0.42 ± 1.6 D [range − 18.38–8.0 D]). The overall prevalence of uncorrected refractive errors among school children in this study was 50.91%. The overall distribution of astigmatism (cylinder error of ≥0.50 D) in the current study population was found to be 50.14% (3688/7356 eyes). CONCLUSION: Nearly half of the study population in this area was affected with at least one type of refractive error. The findings reveal the necessity for implementing timely and sensitive screening programs/methods to identify and correct refractive errors in this age group.
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Compliance with contact lens care and factors driving noncompliance in health-care students in Jeddah, Saudi Arabia p. 75
Nada K Naaman, Suzan Y Alharbi, Muhammad A Khan, Saeed A Alghamdi
PURPOSE: This study aimed to assess compliance to contact lens care behaviors and determine common factors influencing noncompliance among a population of university students in Jeddah, Saudi Arabia. METHODS: This is an observational, cross-sectional study in which a previously validated self-administered questionnaire consisting of 12 questions addressing compliance to contact lens wear and care was E-mailed through the university message center. RESULTS: A total of 388 participants completed the questionnaire. Of those who completed the survey, 150 were contact lens users with an experience of 1 month or more. The average compliance rate to contact lens care was around 66%. High levels of compliance were reported in sharing contact lenses, sleeping with contact lenses, showering/swimming with contact lenses, and using water to clean contact lenses. Moderate levels of compliance were shown in overuse of contact lenses, adherence to instructions of lens cleaning, cleaning the lens case, and adherence to aftercare visits. The lowest levels of compliance were noted in washing hands before lens use and lens case replacement. Gender, smoking, contact lens experience, type and modality of contact lens usage, and contact lens purchase site were found to have a significant association with behaviors showing poor compliance. Believing there is no harm in wearing lenses for longer than the recommended replacement schedule was the primary reason given for overusing contact lenses. CONCLUSION: Moderate levels of compliance were generally reported by respondents, necessitating the need for better strategies to reinforce the importance of compliance to contact lens care in the Saudi population.
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Validation of the Arabic version of the quality of life impact of refractive correction questionnaire p. 83
Kholoud A Bokhary, Elham S Alshamrani, Khalid F Jamous, Rania Fahmy
PURPOSE: To validate the Arabic version of the quality of life impact of refractive correction (QIRC) questionnaire. METHODS: This was a cross-sectional study included participants with refractive errors (myopia, hypermetropia, or astigmatism) aged between 19 and 40 years who were pre or postrefractive surgeries. Uncorrected distance visual acuity, refraction, and corneal topography were collected. The 20-item QIRC questionnaire was translated to the Arabic language and then back translated to the English language. Participants were asked to answer all items of the Arabic QIRC. The validity and reliability of the translated questionnaire were tested using Rasch analysis. RESULTS: A total of 145 participants with refractive errors participated in this study. The mean age ± standard deviation of participants was 26.29 ± 5.1 years. Person separation (2.01) and reliability (0.80) indicates good precision and stability of the Arabic QIRC questionnaire. Item infit was ranged between 0.82 and 1.23; and item outfit was range between 0.76 and 1.32. The items were well targeted to the persons with a mean difference of 0.30. Skew and kurtosis values were within the normal limits (−2.00 to + 2.00). Cronbach's α for the scale was 0.79, which indicates good reliability of the Arabic 20-item QIRC. CONCLUSION: The Arabic 20-item QIRC questionnaire is a valid tool to assess the impact of refractive correction on Arabian participants' quality of life.
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Etiology, clinical profile, and treatment outcome of peripheral ulcerative keratitis p. 90
Sonal Kochhar, Shwetambari Singh, Beena Desai, Dipali Purohit
PURPOSE: To assess the etiology, clinical features, and treatment outcome in patients with peripheral ulcerative keratitis (PUK). METHODS: In this retrospective, observational study, forty-eight eyes of 32 consecutive patients with PUK were included. Demographic profile, etiology, clinical features, treatment history, and outcome were documented. RESULTS: Of the 32 patients, 19 (59%) were male and the mean age at presentation was 54.72 ± 14.92 years. Sixty-eight percent of patients were from rural backgrounds. Half of the patients had bilateral involvement. Fifty percent of patients presented after 4 weeks of the onset of symptoms. Of 48 eyes at presentation, 11 had mild disease, 9 had moderate disease and 28 had severe disease. At presentation, best-corrected visual acuity <3/60 was found in 26 (54%) eyes. Mooren's ulcer (40% eyes) was the most common etiology for PUK. Rheumatoid factor was positive in 8 of 32 patients (25%). Of 32 patients, 19 (59%) required systemic immunosuppression for the control of disease activity. Surgical intervention to maintain anatomical integrity was required in 27 (56%) eyes. No significant change in vision was seen in pretreatment and posttreatment groups. Four eyes failed to heal after 4 weeks of initiation of treatment due to noncompliance of the patient. None of our patients died during follow-up. CONCLUSION: PUK is an indicator of occult systemic autoimmune disease. Mooren's ulcer is the most common cause of PUK. Prompt and adequate immunosuppression is not only eye saving but also lifesaving for patients with PUK of autoimmune origin.
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Changing trends in the corneal transplantation and the impact of the COVID-19 pandemic on corneal transplant recipient selection p. 95
Burak Tanyildiz, Murat Oklar, Nesrin T Günaydın, Baran Kandemir
PURPOSE: The aim of this study was to analyze the trends in the major indications and types of keratoplasty over a 15-year period and to determine the effect of the coronavirus disease-2019 (COVID-19) pandemic on the selection of corneal transplant recipients at a tertiary referral center in Turkey. METHODS: We retrospectively reviewed the data of patients who underwent keratoplasty at the center from January 2006 to March 2021. The keratoplasty indications and types of surgery were evaluated after classification into three groups (period I – January 2006–December 2012; period II – January 2013–March 2020; COVID-19 period – April 2020–March 2021). RESULTS: A total of 5016 corneal transplants were performed in 3862 patients. Lamellar keratoplasty (LK) techniques were found to demonstrate a statistically significantly increasing trend compared to penetrating keratoplasty in the period between 2006 and 2021 (χ2 = 240.55, P < 0.001). The top 4 indications over the 15-year period were aphakic/pseudophakic bullous keratopathy (BK) (1105, 22%), keratoconus (1085, 21.6%), regraft (1084, 21.6%), and keratitis (645, 12.8%). The most common keratoplasty indication during the COVID-19 period was regraft (27, 54.0%), followed by BK (13, 26.0%) and corneal perforation (5, 10%). CONCLUSION: BK was the most common keratoplasty indication at our clinic during the 15-year period. LK rates have been found to increase in recent years, although still not reaching the rates of developed countries. There was a marked decrease in the number of keratoplasties during the COVID-19 pandemic and patients requiring urgent keratoplasty or those who suffered from a painful eye were prioritized.
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Eight-years Egyptian experience of Boston type I keratoprosthesis following failed penetrating keratoplasty or ocular surface disease p. 102
Ihab S Othman, Hesham M Gharieb, Hani M G. Ibrahim
PURPOSE: To evaluate the outcome and complications after implantation of the Boston type I keratoprosthesis (Kpro) in two groups of eyes. METHODS: We retrospectively reviewed records of 28 eyes with failed Penetrating keratoplasty (PKP) (Group A) and 31 eyes with severe ocular surface diseases who implanted Kpro. Follow-up was performed for a mean 37 months. Primary outcomes were Kpro retention and visual improvement, secondary outcomes included the occurrence of complications as endophthalmitis, retro-prosthesis membrane (RPM), intraocular pressure (IOP) abnormalities, posterior capsule opacification (PCO), graft thinning and extrusion. RESULTS: Visual improvement was achieved in 20 eyes in Group A, and in 19 eyes in Group B. In group A, the prosthesis was retained in 25 eyes, while prosthesis retention in Group B was in 26 eyes. Group A had higher rates of PCO, high IOP, soft IOP, and graft thinning. Group B had higher risk of RPM, and endophthalmitis. Two eyes in Group A, and Five eyes in Group B required redo procedure. CONCLUSION: The Boston Kpro type I is an effective procedure in eyes with high risk of keratoplasty failure and in severe ocular surface diseases, it has a high retention rate, higher in cases following failed PKP.
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Safety and efficacy of sodium cromoglycate-fluorometholone fixed combination eye drops in allergic conjunctivitis p. 107
Saeed Alwadani
PURPOSE: This study aimed to assess the efficacy and safety of sodium cromoglycate with fluorometholone in patients with allergic conjunctivitis. METHODS: We conducted a single-arm phase IV open-label trial where fifty patients who received the eye drops were followed for 4 weeks. Treatment efficacy was assessed using the ocular itching score, conjunctival assessment score, total symptom and sign (TSS) score, and Visual Analog Scale (VAS). RESULTS: Patients who received sodium cromoglycate-fluorometholone eye drops experienced significant improvements in their ocular itching score (mean difference [MD]: 1.14, P < 0.001) and conjunctival redness score (MD: 1.18, P < 0.001). Statistically significant improvements in TSS and VAS were achieved in 78% of the patients reporting no conjunctivitis by the end of the study. The overall therapeutic response to the drug was as follows: 16% improved and 84% much improved. No serious adverse events were reported. CONCLUSION: Sodium cromoglycate with fluorometholone eye drops achieved 100% therapeutic response among patients with allergic conjunctivitis. The eye drops improve the ocular itching, and conjunctival irritation without serious adverse events. This combination appears effective and tolerable for treatment of allergic conjunctivitis.
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Effect of eyeliner and mascara use on tear film and meibomian glands p. 113
Zeynep E Ercan
PURPOSE: This study was conducted to see whether eyeliner, mascara, or combined eyeliner and mascara (EM) use affects tear production, tear film stability, and meibomian gland (MG) loss. METHODS: Two hundred and twenty healthy women underwent noninvasive tear break-up time (NTBUT) measurement, meibography, and Schirmer testing. Study groups were no makeup (NM) group, eyeliner-only group, mascara-only group, and those who used both EM. The one-way analysis of variance test was used for group comparisons. Chi-square test was used for meiboscale comparison. RESULTS: NTBUT (seconds) results were 11.5 ± 4.8 (no makeup), 21.3 ± 69 (eyeliner only), 21.8 ± 6.5 (mascara only), and 22.5 ± 7.0 (eyeliner–mascara). The differences between groups were significant (P < 0.0001). All makeup groups (eyeliner only, mascara only, eyeliner–mascara) had significantly diminished values compared with NM group (P < 0.001, P < 0.001 and P = 0.003, respectively). Schirmer test (millimeters) results were 22.7 ± 6.4 (NM group), 21.3 ± 6.9 (eyeliner only), 21.8 ± 6.5 (mascara only), and 22.5 ± 7.0 (eyeliner–mascara) with no significant differences between groups (P = 0.66). Meiboscale grading revealed that NM group had significantly lower values of MG loss compared with eyeliner-only (EO) (P = 0.01), mascara-only (MO) (P = 0.002), and eyeliner-mascara groups (P = 0.007). There were no significant differences between EO and MO (P = 0.31), EO and eyeliner–mascara (P = 0.39), or MO and eyeliner-mascara groups (P = 0.91). CONCLUSION: None of the makeup groups had changes in Schirmer wetting. All eye cosmetic groups have significant changes of NTBUT and meibography compared with NM subjects, and yet combined use of EM does not affect ocular surface more adversely than their separate use.
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Dry eye disease and ocular surface characteristics in patients with keratoconus p. 117
Enver Mirza, Refik Oltulu, Pembe Oltulu, Gunsu D Mirza, Mehmet Okka
PURPOSE: The purpose of this study is to investigate the ocular surface alterations in patients with mild or severe keratoconus (KC). METHODS: A total of 80 participants were included in the study. The corneal topography was performed on each participant using Pentacam and the grouping was done accordingly. The patients with Kmax ≥52.0 D (severe KC) were considered Group 1 (n = 28), the patients with Kmax ≥47.2 and <52.0 D (mild KC) were considered Group 2 (n = 30). Healthy control participants with Kmax <47.2 D were considered Group 3 (n = 22). Tear breakup time (TBUT), Schirmer-I test, ocular surface disease index (OSDI) questionnaire, and conjunctival impression cytology (CIC) were evaluated among the groups. RESULTS: The mean values of TBUT and Schirmer-I test were significantly lower (P = 0.012, P = 0.012) and the mean scores of OSDI and CIC were significantly higher (P = 0.006, P < 0.001) in Group 1 and Group 2 than in Group 3. The mean values of TBUT and Schirmer-I test were lower and the mean scores of OSDI and CIC were higher in Group 1 than in Group 2 but the differences were insignificant (P > 0.05 for all). CONCLUSION: These results indicated that the tests associated with dry eye disease are correlated with KC. Tear film alterations and goblet cell loss are higher in severe KC.
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