Standardised antibacterial Manuka honey in the management of persistent post-operative corneal oedema: A case series

Background Corneal oedema is a common post-operative problem that delays or prevents visual recovery from ocular surgery. Honey is a supersaturated solution of sugars with an acidic pH, high osmolarity and low water content. These characteristics inhibit the growth of micro-organisms, reduce oedema and promote epithelialisation. This clinical case series describes the use of a regulatory approved Leptospermum species honey ophthalmic product, in the management of post-operative corneal oedema and bullous keratopathy. Methods A retrospective review of 18 consecutive cases (30 eyes) with corneal oedema persisting beyond one month after single or multiple ocular surgical procedures (phacoemulsification cataract surgery and additional procedures) treated with Optimel Antibacterial Manuka Eye Drops twice to three times daily as an adjunctive therapy to conventional topical management with corticosteroid, aqueous suppressants, hypertonic sodium chloride five per cent, eyelid hygiene and artificial tears. Visual acuity and central corneal thickness were measured before and at the conclusion of Optimel treatment. Results A temporary reduction in corneal epithelial oedema lasting up to several hours was observed after the initial Optimel instillation and was associated with a reduction in central corneal thickness, resolution of epithelial microcysts, collapse of epithelial bullae, improved corneal clarity, improved visualisation of the intraocular structures and improved visual acuity. Additionally, with chronic use, reduction in punctate epitheliopathy, reduction in central corneal thickness and improvement in visual acuity were achieved. Temporary stinging after Optimel instillation was experienced. No adverse infectious or inflammatory events occurred during treatment with Optimel. Conclusions Optimel was a safe and effective adjunctive therapeutic strategy in the management of persistent post-operative corneal oedema and warrants further investigation in clinical trials.

Corneal changes following short-term miniscleral contact lens wear

Purpose To examine the influence of short-term miniscleral contact lens wear on corneal shape, thickness and anterior surface aberrations. Methods Scheimpflug imaging was captured before, immediately following and 3 hours after a short period (3 hours) of miniscleral contact lens wear for 10 young (mean 27 ± 5 years), healthy participants. Natural diurnal variations were considered by measuring baseline diurnal changes obtained on a separate control day without contact lens wear. Results Small but significant anterior corneal flattening was observed immediately following lens removal (overall mean 0.02 ± 0.03 mm, p < 0.001) which returned to baseline levels three hours after lens removal. During the three hour recovery period significant corneal thinning (-13.4 ± 10.5 μm) and posterior surface flattening (0.03 ± 0.02 mm) were also observed (both p < 0.01). The magnitude of posterior corneal flattening during recovery correlated with the amount of corneal thinning (r = 0.69, p = 0.03). Central corneal clearance (maximum tear reservoir depth) was not associated with corneal swelling following lens removal (r = -0.24, p > 0.05). An increase in lower-order corneal astigmatism Z(2,2) was also observed following lens wear (mean -0.144 ± 0.075 μm, p = 0.02). Conclusions Flattening of the anterior corneal surface was observed immediately following lens wear, while ‘rebound’ thinning and flattening of the posterior surface was evident following the recovery period. Modern miniscleral contact lenses that vault the cornea may slightly influence corneal shape and power but do not induce clinically significant corneal oedema during short-term wear.

Hypoxic corneal changes following 8 hours of scleral contact lens wear

- Purpose To examine the change in corneal thickness and posterior curvature following 8 hours of miniscleral contact lens wear. - Methods Scheimpflug imaging (Pentacam HR, Oculus) was captured before, and immediately following, 8 hours of miniscleral contact lens wear for 15 young (mean age 22 ± 3 years), healthy participants with normal corneae. Natural diurnal variations were considered by measuring baseline corneal changes obtained on a separate control day without contact lens wear. - Results Over the central 6 mm of the cornea, a small, but highly statistically significant amount of edema was observed following 8 hours of miniscleral lens wear, after accounting for normal diurnal fluctuations (mean ± standard deviation percentage swelling 1.70 ± 0.98%, p < 0.0001). Posterior corneal topography remained stable following lens wear (-0.01 ± 0.07 mm steepening over the central 6 mm, p = 0.60). The magnitude of posterior corneal topographical changes following lens wear did not correlate with the extent of lens-related corneal edema (r = -0.16, p = 0.57). Similarly, the initial central corneal vault (maximum post-lens tear layer depth) was not associated with corneal swelling following lens removal (r = 0.27, p = 0.33). - Conclusions While a small amount of corneal swelling was induced following 8 hours of miniscleral lens wear (on average <2%), modern high Dk miniscleral contact lenses that vault the cornea do not induce clinically significant corneal edema or hypoxic related posterior corneal curvature changes during short-term wear. Longer-term studies of compromised eyes (e.g. corneal ectasia) are still required to inform the optimum lens and fitting characteristics for safe scleral lens wear to minimize corneal hypoxia.

Corneal sensitivity and slit scanning in vivo confocal microscopy of the subbasal nerve plexus of the normal central and peripheral human cornea

Purpose: To determine the subbasal nerve density and tortuosity at 5 corneal locations and to investigate whether these microstructural observations correlate with corneal sensitivity. Method: Sixty eyes of 60 normal human subjects were recruited into 1 of 3 age groups, group 1: aged ,35 years, group 2: aged 35–50 years, and group 3: aged .50 years. All eyes were examined using slit-lamp biomicroscopy, noncontact corneal esthesiometry, and slit scanning in vivo confocal microscopy. Results: The mean subbasal nerve density and the mean corneal sensitivity were greatest centrally (14,731 6 6056 mm/mm2 and 0.38 6 0.21 millibars, respectively) and lowest in the nasal mid periphery (7850 6 4947 mm/mm2 and 0.49 6 0.25 millibars, respectively). The mean subbasal nerve tortuosity coefficient was greatest in the temporal mid periphery (27.3 6 6.4) and lowest in the superior mid periphery (19.3 6 14.1). There was no significant difference in mean total subbasal nerve density between age groups. However, corneal sensation (P = 0.001) and subbasal nerve tortuosity (P = 0.004) demonstrated significant differences between age groups. Subbasal nerve density only showed significant correlations with corneal sensitivity threshold in the temporal cornea and with subbasal nerve tortuosity in the inferior and nasal cornea. However, these correlations were weak. Conclusions: This study quantitatively analyzes living human corneal nerve structure and an aspect of nerve function. There is no strong correlation between subbasal nerve density and corneal sensation. This study provides useful baseline data for the normal living human cornea at central and mid-peripheral locations

Corneal confocal microscopy : a novel noninvasive means to diagnose neuropathy in patients with Fabry disease

ABSTRACT: Neuropathy is a cause of significant disability in patients with Fabry disease, yet its diagnosis is difficult. In this study we compared the novel noninvasive techniques of corneal confocal microscopy (CCM) to quantify small-fiber pathology, and non-contact corneal esthesiometry (NCCA) to quantify loss of corneal sensation, with established tests of neuropathy in patients with Fabry disease. Ten heterozygous females with Fabry disease not on enzyme replacement therapy (ERT), 6 heterozygous females, 6 hemizygous males on ERT, and 14 age-matched, healthy volunteers underwent detailed quantification of neuropathic symptoms, neurological deficits, neurophysiology, quantitative sensory testing (QST), NCCA, and CCM. All patients with Fabry disease had significant neuropathic symptoms and an elevated Mainz score. Peroneal nerve amplitude was reduced in all patients and vibration perception threshold was elevated in both male and female patients on ERT. Cold sensation (CS) threshold was significantly reduced in both male and female patients on ERT (P < 0.02), but warm sensation (WS)and heat-induced pain (HIP) were only significantly increased in males onERT (P<0.01). However, corneal sensation assessed withNCCAwas significantly reduced in female (P < 0.02) and male (P < 0.04) patients on ERT compared with control subjects. According to CCM, corneal nerve fiber and branch density was significantly reduced in female (P < 0.03) and male (P < 0.02) patients on ERT compared with control subjects. Furthermore, the severity of neuropathic symptoms and the neurological component of the Mainz Severity Score Index correlated significantly with QSTand CCM. This study shows that CCM and NCCA provide a novel means to detect early nerve fiber damage and dysfunction, respectively, in patients with Fabry disease.

Aberrations and pupil location under corneal topography and Hartmann-Shack illumination conditions

PURPOSE. This study was conducted to determine the magnitude of pupil center shift between the illumination conditions provided by corneal topography measurement (photopic illuminance) and by Hartmann-Shack aberrometry (mesopic illuminance) and to investigate the importance of this shift when calculating corneal aberrations and for the success of wavefront-guided surgical procedures. METHODS. Sixty-two subjects with emmetropia underwent corneal topography and Hartmann-Shack aberrometry. Corneal limbus and pupil edges were detected, and the differences between their respective centers were determined for both procedures. Corneal aberrations were calculated using the pupil centers for corneal topography and for Hartmann-Shack aberrometry. Bland-Altmann plots and paired t-tests were used to analyze the differences between corneal aberrations referenced to the two pupil centers. RESULTS. The mean magnitude (modulus) of the displacement of the pupil with the change of the illumination conditions was 0.21 ± 0.11 mm. The effect of this pupillary shift was manifest for coma corneal aberrations for 5-mm pupils, but the two sets of aberrations calculated with the two pupil positions were not significantly different. Sixty-eight percent of the population had differences in coma smaller than 0.05 µm, and only 4% had differences larger than 0.1 µm. Pupil displacement was not large enough to significantly affect other higher-order Zernike modes. CONCLUSIONS. Estimated corneal aberrations changed slightly between photopic and mesopic illumination conditions given by corneal topography and Hartmann-Shack aberrometry. However, this systematic pupil shift, according to the published tolerances ranges, is enough to deteriorate the optical quality below the theoretically predicted diffraction limit of wavefront-guided corneal surgery.

Diurnal variation of corneal shape and thickness

Purpose: To investigate associations between the diurnal variation in a range of corneal parameters, including anterior and posterior corneal topography, and regional corneal thickness. ----- Methods: Fifteen subjects had their corneas measured using a rotating Scheimpflug camera (Pentacam) every 3-7 hours over a 24-hour period. Anterior and posterior corneal axial curvature, pachymetry and anterior chamber depth were analysed. The best fitting corneal sphero-cylinder from the axial curvature, and the average corneal thickness for a series of different corneal regions were calculated. Intraocular pressure and axial length were also measured at each measurement session. Repeated measures ANOVA were used to investigate diurnal change in these parameters. Analysis of covariance was used to examine associations between the measured ocular parameters. ----- Results: Significant diurnal variation was found to occur in both the anterior and posterior corneal curvature and in the regional corneal thickness. Flattening of the anterior corneal best sphere was observed at the early morning measurement (p < 0.0001). The posterior cornea also underwent a significant steepening (p < 0.0001) and change in astigmatism 90/180° at this time. A significant swelling of the cornea (p < 0.0001) was also found to occur immediately after waking. Highly significant associations were found between the diurnal variation in corneal thickness and the changes in corneal curvature. ----- Conclusions: Significant diurnal variation occurs in the regional thickness and the shape of the anterior and posterior cornea. The largest changes in the cornea were typically evident upon waking. The observed non-uniform regional corneal thickness changes resulted in a steepening of the posterior cornea, and a flattening of the anterior cornea to occur at this time.

Corneal topography with Scheimpflug imaging and videokeratography : comparative study of normal eyes

PURPOSE: To compare the repeatability within anterior corneal topography measurements and agreement between measurements with the Pentacam HR rotating Scheimpflug camera and with a previously validated Placido disk–based videokeratoscope (Medmont E300). ------ SETTING: Contact Lens and Visual Optics Laboratory, School of Optometry, Queensland University of Technology, Brisbane, Queensland, Australia. ----- METHODS: Normal eyes in 101 young adult subjects had corneal topography measured using the Scheimpflug camera (6 repeated measurements) and videokeratoscope (4 repeated measurements). The best-fitting axial power corneal spherocylinder was calculated and converted into power vectors. Corneal higher-order aberrations (HOAs) (up to the 8th Zernike order) were calculated using the corneal elevation data from each instrument. ----- RESULTS: Both instruments showed excellent repeatability for axial power spherocylinder measurements (repeatability coefficients <0.25 diopter; intraclass correlation coefficients >0.9) and good agreement for all power vectors. Agreement between the 2 instruments was closest when the mean of multiple measurements was used in analysis. For corneal HOAs, both instruments showed reasonable repeatability for most aberration terms and good correlation and agreement for many aberrations (eg, spherical aberration, coma, higher-order root mean square). For other aberrations (eg, trefoil and tetrafoil), the 2 instruments showed relatively poor agreement. ----- CONCLUSIONS: For normal corneas, the Scheimpflug system showed excellent repeatability and reasonable agreement with a previously validated videokeratoscope for the anterior corneal axial curvature best-fitting spherocylinder and several corneal HOAs. However, for certain aberrations with higher azimuthal frequencies, the Scheimpflug system had poor agreement with the videokeratoscope; thus, caution should be used when interpreting these corneal aberrations with the Scheimpflug system.

Enhancing the standard operating range of a placido disk videokeratoscope for corneal surface estimation

Abstract—Corneal topography estimation that is based on the Placido disk principle relies on good quality of precorneal tear film and sufficiently wide eyelid (palpebral) aperture to avoid reflections from eyelashes. However, in practice, these conditions are not always fulfilled resulting in missing regions, smaller corneal coverage, and subsequently poorer estimates of corneal topography. Our aim was to enhance the standard operating range of a Placido disk videokeratoscope to obtain reliable corneal topography estimates in patients with poor tear film quality, such as encountered in those diagnosed with dry eye, and with narrower palpebral apertures as in the case of Asian subjects. This was achieved by incorporating in the instrument’s own topography estimation algorithm an image processing technique that comprises a polar-domain adaptive filter and amorphological closing operator. The experimental results from measurements of test surfaces and real corneas showed that the incorporation of the proposed technique results in better estimates of corneal topography, and, in many cases, to a significant increase in the estimated coverage area making such an enhanced videokeratoscope a better tool for clinicians.

Modeling corneal surfaces with rational functions for high-speed videokeratoscopy data compression

High-speed videokeratoscopy is an emerging technique that enables study of the corneal surface and tear-film dynamics. Unlike its static predecessor, this new technique results in a very large amount of digital data for which storage needs become significant. We aimed to design a compression technique that would use mathematical functions to parsimoniously fit corneal surface data with a minimum number of coefficients. Since the Zernike polynomial functions that have been traditionally used for modeling corneal surfaces may not necessarily correctly represent given corneal surface data in terms of its optical performance, we introduced the concept of Zernike polynomial-based rational functions. Modeling optimality criteria were employed in terms of both the rms surface error as well as the point spread function cross-correlation. The parameters of approximations were estimated using a nonlinear least-squares procedure based on the Levenberg-Marquardt algorithm. A large number of retrospective videokeratoscopic measurements were used to evaluate the performance of the proposed rational-function-based modeling approach. The results indicate that the rational functions almost always outperform the traditional Zernike polynomial approximations with the same number of coefficients.

Comparison of high-speed videokeratoscopy and ultrasound distance sensing for measuring the longitudinal corneal apex movements

Two different methods to measure binocular longitudinal corneal apex movements were synchronously applied. High-speed videokeratoscopy at a sampling frequency of 15 Hz and a customdesigned ultrasound distance sensor at 100 Hz were used for the left and the right eye, respectively. Four healthy subjects participated in the study. Simultaneously, cardiac electric cycle (ECG) was registered for each subject at 100 Hz. Each measurement took 20 s. Subjects were asked to suppress blinking during the measurements. A rigid headrest and a bite-bar were used to minimize undesirable head movements. Time, frequency and time-frequency representations of the acquired signals were obtained to establish their temporal and spectral contents. Coherence analysis was used to estimate the correlation between the measured signals. The results showed close correlation between both corneal apex movements and the cardiopulmonary system. Unraveling these relationships could lead to better understanding of interactions between ocular biomechanics and vision. The advantages and disadvantages of the two methods in the context of measuring longitudinal movements of the corneal apex are outlined.

Determining the zone of reflection for posterior corneal surface comparison phakometry

Although comparison phakometry has been used by a number of studies to measure posterior corneal shape, these studies have not calculated the size of the posterior corneal zones of reflection they assessed. This paper develops paraxial equations for calculating posterior corneal zones of reflection, based on standard keratometry equations and equivalent mirror theory. For targets used in previous studies, posterior corneal reflection zone sizes were calculated using paraxial equations and using exact ray tracing, assuming spherical and aspheric corneal surfaces. Paraxial methods and exact ray tracing methods give similar estimates for reflection zone sizes less than 2 mm, but for larger zone sizes ray tracing methods should be used.