Carolina Mercado

Introduction: Corneal endothelial dysfunction, most commonly caused by Fuchs endothelial corneal dystrophy (FECD) or pseudophakic bullous keratopathy (PBK), leads to stromal edema and corneal decompensation when endothelial cell density (ECD) falls below 500–700cells/mm². Standard treatment via corneal transplantation, including Descemet stripping automated endothelial keratoplasty (DSAEK) and Descemet membrane endothelial keratoplasty (DMEK), is limited by the need to standardize corneal endothelial cell culture, donor shortages, immune rejection, and technical complications. This review aims to summarize recent advances in injectable corneal endothelial cell (CEC) therapy, critically appraise translational challenges, and discuss future directions for establishing this regenerative approach as a global treatment. Design: Narrative review of pre-clinical and clinical studies examining CEC injection therapy. Methods: Relevant literature was analyzed to evaluate innovations in Human corneal endothelial cells (HCEC) preparation, culture techniques, delivery methods, and strategies to enhance cell adhesion and survival. Studies reporting preclinical models and human clinical trials were included to assess safety, efficacy, and translational feasibility. Results: Corneal endothelial cells (CEC) injections have achieved significant advancement since their development. Simple cultured CEC injections showed poor efficacy due to limited cell adhesion and survival, but the introduction of ROCK inhibitors along with cultured CECs demonstrated improvement in corneal transparency up to 5 years. Advancements in cell delivery techniques like hydrogel, carrier-assisted injections, magnetically guided injections, as well as alternative cell sources have shown promising results in pre-clinical studies, but human studies are still ongoing. Despite advancements, persisting challenges include phenotypic stability, and longterm safety and efficacy. Discussion: Injectable CEC therapy is a promising minimally invasive alternative to corneal transplantation. While early clinical outcomes are encouraging, further work is required to optimize cell preparation, delivery, and long-term safety, and to establish the therapy as a scalable, globally applicable treatment for endothelial failure.

Introduction Lifitegrast ophthalmic solution 5% is indicated to treat signs and symptoms of dry eye disease (DED). This study assessed eyecare professionals’ (ECPs) real-world experiences with lifitegrast in DED. Methods A total of 12 ECPs (6 ophthalmologists and 6 optometrists) with experience prescribing lifitegrast completed a cross-sectional survey on practice characteristics, lifitegrast utilization, satisfaction, and adverse events (AEs). ECPs rated satisfaction with lifitegrast overall and for specific clinical outcomes versus other prescription eye drops on a 1 (very dissatisfied) to 10 (very satisfied) Likert scale. Results ECPs reported a mean of 1288 (range, 35–6000) patients with DED treated annually, with 20.9% receiving lifitegrast. Overall, 66.7% of ECPs reported near/complete symptom resolution in patients after 1–3 months of lifitegrast treatment. Mean (range) satisfaction ratings for onset/effectiveness were 6.8 (3–9)/6.6 (3–9). Satisfaction with reduction of DED signs was generally high: increased tear film breakup time, 5.8 (3–9); reduced conjunctival/corneal staining, 6.9 (3–9); increased Schirmer test score, 6.0 (3–9); increased tear meniscus height, 6.0 (3–9); and reduced Ocular Surface Disease Index severity, 7.0 (3–10). Symptom reduction satisfaction ratings were: itching, 5.3 (1–9); dryness, 6.9 (3–9); burning/stinging, 6.3 (1–9); redness, 6.2 (4–9); pain, 6.3 (3–9); light sensitivity, 6.5 (3–9); and blurred/poor vision, 6.8 (4–9). Overall satisfaction (ECPs/patients) was rated 7.1 (3–10)/6.8 (2–9). Predominant uses of lifitegrast included contact lens-induced DED (91.7%) and DED before/after refractive or cataract surgery (83.3% each). AEs reported were consistent with the known AE profile of lifitegrast and included burning/stinging, blurred vision, and dysgeusia. Conclusions This real-world survey showed that ECPs use lifitegrast to treat one fifth of their patients with DED and reported moderate-to-high personal and patient satisfaction with lifitegrast treatment.

Background/aims: Corneal endothelial cell loss contributes to transplant failure. Autologous plasma products (APP) activate salvaging pathways that can prevent oxidative stress perioperatively. This study aimed to evaluate the safety of intraoperative incubation of full-thickness corneal grafts in platelet-rich plasma (aPRP) and plasma rich in growth factors (PRGF-Endoret) in mitigating postoperative corneal endothelial cell loss (ECL).Methods: Pilot study including patients undergoing penetrating keratoplasty (PK) for various indications between June 2021 and December 2022. Patients were randomly assigned to receive either aPRP or PRGF-Endoret incubation, while those who declined intervention served as the control group. Demographic and clinical data were collected, including preoperative and postoperative endothelial cell count, intraocular pressure, pachymetry, and adverse reactions.Results: Thirty individuals who underwent PK completed follow-up: eight from the aPRP group, 10 from the PRGF-Endoret group, and 12 from the control group. No adverse events related to APP treatment were recorded. In the first and third postoperative months, the APP group had significantly lower ECL percentages (37% vs. 25%, p = 0.02, and 44% vs. 33%, p = 0.02, respectively); this trend was maintained in the sixth month. When stratified, the PRGF-Endoret group showed significant differences in ECL reduction compared to controls at both time points (p = 0.03 and p = 0.05, respectively). The aPRP group showed a similar statistically significant outcome exclusively on the third postoperative month (p = 0.04). APP tended to reduce corneal edema faster than controls. Hexagonality was significantly better in the APP groups in the first and third months, particularly in the PRGF-Endoret group (p < 0.005).Conclusion: Preoperative incubation with APP is safe and promotes better endothelial cell quality and quantity in the early postoperative period following PK. These findings suggest a potential clinical benefit in enhancing graft outcomes and warrant further investigation.

Background: The cause of ocular pain in the quiet eye is challenging to diagnose. It is a common complaint in the ophthalmology clinic and there are no actual guidelines on the exams that should be ordered initially. We decided to characterize patients with eye pain and normal ophthalmological examination who underwent ocular ultrasound, their findings, and systemic work-up. Methods: A retrospective chart review of patients who underwent ocular ultrasound due to ocular pain and no clinical findings on initial slit-lamp examination. We evaluated patient characteristics and analyzed systemic work-up results in contrast to ocular ultrasound findings. Results: Two hundred and three patients with normal slit-lamp examination and ocular pain were evaluated using ocular ultrasound at Clinica Barraquer. Most of the patients were women (88.7%), and 55% were older than 50 years. Nearly all of the patients had echographic findings, 87.7% of patients showed evidence of scleral scars, from which 66.5% had signs of activity, and 42.9% had thickened extraocular muscles. In general, most patients with ocular pain had normal results on systemic work-up, but the patients who did have positive results tended to have echographic findings. Conclusion: Posterior inflammation is present in most patients with ocular pain in a quiet eye, and echography is an optimal tool to identify this. There is a tendency towards abnormal autoimmune test results and echographic findings. This should be considered in the initial work-up of these patients, given the importance of early diagnosis and the threat of vision loss with severe inflammation.

Dry eye has two basic subdivisions: aqueous deficient dry eye (ADDE), with SS a major cause; and evaporative dry eye (EDE), due to either intrinsic or extrinsic factors. SS is a chronic inflammatory disorder defined by dysfunction of the exocrine glands leading to dry eye and dry mouth. The objective of this article was to carry out a systematic and critical review of several scientific publications on dry eye disease, with the aim of providing general recommendations to distinguish dry eye and its different variants in patients with SS, during the period 1979 to 2020, using search engines for articles indexed in Scopus, Latindex, Scielo, Clinical Trials, Medline, Embase, and Cochrane, allowing the analysis of 132 articles published in indexed journals on the subject of dry eye disease and SS, evidencing its conceptualization, prevalence, risk factors, etiopathogenesis, clinical manifestations, diagnosis, and treatment.

An asymptomatic 26-year-old woman underwent confocal microscopy as part of a control population for a research study. Images revealed reduced sub-basal corneal nerve density and multiple activated dendritic cells. Three years later, she presented with a self-limited cutaneous vasculitis in her lower extremities which prompted an evaluation for autoimmune diseases. Laboratory testing revealed positive antinuclear antibodies (1:320, thick granular pattern), and anti-SSA/SSB (SSA, 53.6 U/mL, moderately positive; SSB, 142.7 U/mL, strongly positive). Two weeks later, she presented with ocular pain and an ophthalmologic examination revealed ocular surface staining. An ocular ultrasound was consistent with posterior scleritis. Based on this picture, a diagnosis of Sjögren syndrome (SS) was made. SS is a chronic autoimmune disease that can present with symptoms that diminish the patient’s quality of life. Confocal microscopy might be a valuable tool for the early diagnosis of disease.

Purpose: To report a case of epithelial downgrowth after penetrating keratoplasty. Case description: A 58-year-old man presented with graft rejection in his three-month-old, repeat penetrating keratoplasty. Examination revealed centripetal opacification of the posterior cornea due to deep epithelization. He had new retro-corneal membranes and anterior uveitis. Specular microscopy and anterior segment optical coherence tomography were performed, and a clinical diagnosis of epithelial downgrowth was made. The patient had intracameral injections with 5-fluorouracil (5FU) and achieved resolution of intraocular findings after treatment. Conclusions: Epithelial downgrowth is an uncommon complication of penetrating keratoplasty. It affects the patients’ visual acuity and graft survival. Clinical observation is preferred in severe cases due to the high risk of intraocular damage; intracameral 5FU promises to be a good option in these cases.