Biljana Kuzmanović Elabjer

Purpose: To evaluate short-term refractive outcomes, binocular defocus curves, visual phenomena, and intraocular lens (IOL) power calculation accuracy following implantation of the Clareon® monofocal (CNA0T0) IOL. Methods: This was a prospective, single-arm clinical study. The study enrolled consecutive patients without prior ocular surgery or significant ocular pathology. All eyes underwent phacoemulsification and implantation of a CNA0T0 IOL. Primary endpoints were binocular distance and intermediate visual acuity; secondary endpoints included refractive accuracy, binocular defocus curves, visual phenomena, and IOL glistenings. Outcomes were measured up to 3 months postoperatively-sufficient to assess early refractive stability. Results: Fifty participants (90 eyes) were enrolled, and 44 participants (88 eyes) completed the study. At 3 months, binocular distance-corrected defocus curves demonstrated favorable intermediate visual performance, with a mean visual acuity of 0.10 logMAR at − 1.50 D (66 cm) and 0.30 logMAR at − 2.50 D (40 cm). Dysphotopsias were infrequent, no IOL glistenings were observed on slit-lamp or SD-OCT examination during the 3-month follow-up, and cystoid macular edema occurred in 3 eyes (3.4%) at 1 month. The mean spherical equivalent at 3 months was − 0.25 ± 0.38 D in myopic eyes, − 0.09 ± 0.44 D in emmetropic eyes, and − 0.10 ± 0.42 D in hyperopic eyes, with 82– 85% of eyes within ± 0.50 D of the target refraction. Conclusions: The CNA0T0 IOL demonstrated favorable short-term refractive accuracy and binocular functional intermediate visual outcomes, with minimal dysphotopsia and no glistenings detected at 3 months. The Barrett Universal II and Hoffer QST formulas provided accurate refractive predictions across refractive subgroups in this cohort.

Background: Severe involutional lower eyelid ectropion with complete eyelid eversion represents an advanced stage of eyelid malposition in which long-standing involutional changes may be accompanied by secondary structural remodeling of the posterior lamella. Although conventional surgical techniques are generally effective in mild to moderate cases, the management of end-stage involutional ectropion remains challenging. Methods: This retrospective single-center case series included nine patients treated for severe involutional lower eyelid ectropion with complete eyelid eversion between January 2024 and December 2025. Surgical treatment consisted of horizontal eyelid tightening, with adjunctive procedures performed according to intraoperative findings. Lower eyelid retractors were managed by reattachment, tightening, or complete release based on intraoperative clinical judgment when marked fibrosis, shortening, and persistent inferior traction were identified. Clinical outcomes were analyzed descriptively. Results: Complete lower eyelid retractor release was performed in three patients during primary surgery and two during revision surgery. The remaining patients underwent retractor tightening or reattachment. During a mean follow-up of 10.5 months, recurrent ectropion occurred in five of six patients treated with retractor tightening or reattachment. No recurrence was observed after complete retractor release, either as a primary or revision procedure. Revision surgery including complete retractor release restored a stable eyelid position in all reoperated patients during the available follow-up period. Conclusions: Complete lower eyelid retractor release was associated with favorable anatomical outcomes in this small retrospective case series of selected patients with intraoperative evidence of marked retractor fibrosis or shortening. These findings are descriptive and hypothesis-generating and should be interpreted within the limitations of the study.

Background/Objectives: To describe a previously unreported compensatory behavior used by an infant with severe bilateral congenital ptosis associated with blepharophimosis syndrome (BPES). Methods: Observational case report of a 4.5-month-old infant with severe bilateral congenital upper eyelid ptosis due to BPES. Results: The infant demonstrated classic compensatory mechanisms, including frontalis overaction and chin elevation, which were insufficient to clear the visual axis. Notably, she repeatedly used the dorsal surfaces of both fists to elevate the upper eyelids simultaneously and maintain fixation on faces. This behavior ceased following bilateral frontalis suspension surgery with silicone rods. Conclusions: In early infancy, severe bilateral ptosis may prompt the emergence of alternative, developmentally constrained compensatory behaviors. The bilateral fist lid-lift appears to represent a visually driven, sensorimotor strategy to clear the visual axis when conventional mechanisms are ineffective. Recognition of this behavior expands understanding of early compensatory responses in congenital ptosis and BPES.

Introduction: Active Surge Mitigation (ASM) is a feature of the Centurion Vision System ACTIVE SENTRY^® Handpiece designed to minimize post-occlusion surge by dynamically adjusting fluidics. Stable anterior chamber conditions are critical during phacoemulsification, and low intraocular pressure (IOP) fluidics may enhance surgical safety by reducing stress on ocular tissues. This study evaluated demographic, biometric, and intraoperative factors influencing ASM activation during phacoemulsification at low IOP settings (30 mmHg), a vacuum of 575 mmHg, and an aspiration flow of 28 cc/min. Methods: This retrospective study was conducted at the University Eye Clinic, University Hospital “Sveti Duh” in Zagreb, Croatia, between January 19 and April 12, 2024. Preoperative parameters included age, gender, biometric data from the Zeiss IOL Master 700, and lens hardness, classified according to the Lens Opacities Classification System (LOCS III). The presence of Pseudoexfoliation Syndrome (PEX) and Intraoperative Floppy Iris Syndrome (IFIS) was noted. Intraoperative metrics recorded were total case time, cumulative dissipated energy (CDE), ultrasound time (U/S time), and the number of ASM actuations. Results: ASM actuations were not normally distributed (median = 1; mean = 2.4). Significant positive correlations were identified with age (P = 0.014), lens thickness (P = 0.039), and U/S time (P = 0.015), while no significant differences were observed for anterior chamber depth (ACD), gender, PEX, or IFIS. Logistic regression identified age as a predictor of ASM values ≥ 1. Conclusion: At low IOP settings, surge events during phacoemulsification are rare. ASM activation is influenced by patient age, lens thickness, and U/S time but not by ACD, gender, PEX, or IFIS. Low IOP fluidics combined with ASM contributes to stable and safe chamber dynamics across diverse patient profiles.

Disease-causing variants in the IDH3A gene are associated with autosomal recessive retinitis pigmentosa 90 (RP90) and Leber congenital amaurosis, with or without macular pseudocoloboma. Here, we report two patients: one compound heterozygous for IDH3A c.364G>A, p.(Ala122Thr), which has conflicting classifications, and for IDH3A c.293C>T, p.(Pro98Leu), which is likely pathogenic, and the other homozygous for IDH3A c.364G>A, p.(Ala122Thr). This study is aimed at providing evidence to link the latter variants to a clinical phenotype. The first patient was a 6-year-old girl, and the second patient was a 29-year-old female. In both patients, the diagnostic assessments were consistent with the phenotype of RP, characterized by macular pseudocoloboma but of varying severity. Patients’ phenotypes suggest that the c.293C>T, p.(Pro98Leu) variant is linked to a more severe and extensive clinical phenotype, while the c.364G>A, p.(Ala122Thr) variant results in a milder condition, primarily limited to retinal involvement. In Patient 2, the presence of both global and local stereopsis, indicating advanced visual development, suggests that the p.(Ala122Thr) missense variant may act as a hypomorphic allele which likely allows for some residual enzymatic activity of the IDH3A protein. This report highlights that macular pseudocoloboma can manifest even in the absence of a null variant. In contrast, more severe symptoms, such as mitochondrial encephalopathy, seem to be associated with the presence of a null allele. Furthermore, to the best of our knowledge, this is the first report of the IDH3A c.293C>T, p.(Pro98Leu) variant.

Background/Objectives: This case report presents a unique case of multiple postoperative complications, including sterile silicone implant extrusion, symblepharon formation, and the development of a giant cyst, following extensive multimodal chemotherapy for unilateral retinoblastoma in a pediatric patient. The case was further complicated by recurrent methicillin-resistant Staphylococcus aureus (MRSA) colonization, which persisted despite multiple eradication attempts. Methods: A 5-year-old boy presented with right-sided proptosis one year after receiving a secondary dermis-fat orbital graft. He had undergone 12 cycles of intravitreal, intra-arterial, and systemic chemotherapy as well as thermotherapy and cryotherapy due to recurrent retinoblastoma in the right eye. Following a third relapse, secondary enucleation was performed with a primary silicone orbital implant. However, extrusion of the implant occurred, and an orbital swab confirmed MRSA colonization. A secondary dermis-fat graft was harvested and implanted after ensuring MRSA clearance. A year later, the child developed rapid right-sided proptosis. Ultrasound revealed a cyst within the dermis-fat graft measured 23.6 mm in anteroposterior diameter. Surgery was postponed due to chickenpox, and the cyst enlarged reaching an anteroposterior diameter of 26.7 mm over two months. A complete excision was performed. Results: The surgery was uneventful. Intraoperative orbital swab was sterile, but MRSA was detected in a conjunctival swab, leading to treatment with local moxifloxacin drops and oral rifampicin. Conclusions: Giant cyst formation in a dermis-fat graft is an extremely rare complication. Complete excision remains the treatment of choice. However, in this case, it resulted in persistent anophthalmic socket syndrome, posing further reconstructive challenges.

We present two children aged 3 and 5 years who share identical TYR genotype, yet exhibit contrasting phenotypic manifestations in terms of eye, skin, and hair coloration. The patients are heterozygous for TYR c.1A>G, p. (Met1?), which is pathogenic, and homozygous for TYR c.1205G>A, p. (Arg402Gln), which is classified as a risk factor. The children manifested diminished visual acuity, nystagmus, and foveal hypoplasia. The first patient presented with hypopigmentation of the skin, hair, and ocular tissues, while the second patient presented with hypopigmentation of the skin, hair, retinal pigment epithelium, and choroid with dark brown irises. Furthermore, the brown-eyed subject presented astigmatic refractive error and both global and local stereopsis capabilities, contrasting with the presentation of hypermetropia, strabismus, and the absence of stereopsis in the blue-eyed individual. Herein, we propose a genotype–phenotype correlation model to elucidate the diverse clinical presentations stemming from biallelic and triallelic pathogenic variants in TYR, establishing a link between the residual tyrosinase activity and resultant phenotypes. According to our proposed model, the severity of TYR variants correlates with distinct albino phenotypes. Our findings propose the potential association between reduced pigmentation levels in ocular tissues and binocular functions, suggesting pigmentation as a possible independent variable influencing the onset of strabismus—an association unreported until now in the existing literature.

The purpose was to define the threshold of normal visual acuity (VA), mean monocular and binocular VA, and interocular difference in the uniform cohort of healthy four-year-old children. All the children were recruited from the Croatian National Registry of Early Amblyopia Detection database. LEA Symbols^® inline optotypes were used for VA testing at near and distance, binocularly and monocularly. The pass cut-off level was set to ≤0.1 logMAR. The final sample consisted of 58,712 four-year-old children. In total, 83.78% of the children had unremarkable results, and 16.22% of the children were referred to examination. Of those, 92% of the children were referred due to binocular, and 8% of the children due to monocular causes. The children referred due to binocular causes demonstrated a VA of 0.3 ± 0.24, while the children referred due to monocular causes 0.6 ± 0.21. The ROC curve analysis defined the uniform cut-off value for a normative VA of 0.78. We analyzed the largest uniform cohort of 58,712 children, and have determined normative data for binocular and monocular VA tested with gold standard logMAR chart in four-year-old children. The results presented here established no reasoning to further utilize historical protocols in testing VA in preschool children aged ≥ 4 years.

We present a case involving a patient whose clinical phenotype aligns with oculocutaneous albinism (OCA), yet exhibits a complex genotype primarily characterized by variants of unknown significance (VUS). An 11-year-old boy manifested iris hypopigmentation and translucency, pronounced photophobia, diminished visual acuity and stereopsis, nystagmus, reduced pigmentation of the retina, and foveal hypoplasia. Genetic testing was performed. A heterozygous missense VUS CAPN5 c.230A>G, p.(Gln77Arg), a heterozygous missense VUS TYR c.1307G>C, p.(Gly436Ala), and a heterozygous missense variant TYR c.1205G>A, p.(Arg402Gln) which was classified as a risk factor, were identified. We hypothesized that the TYR c.1307G>C, p.(Gly436Ala) variant is in genetic disequilibrium with the TYR c.1205G>A, p.(Arg402Gln) variant leading to deficient expression of melanogenic enzymes in retinal cells, resulting in the manifestation of mild OCA. Additionally, this study represents the case where we did not detect chiasmal misrouting in visual evoked potentials, nor did we observe a shift in the distribution of ganglion cell thickness from a temporal to a central position. Moreover, our patient’s case supports the probable benign nature of the CAPN5 c.230A>G, p.(Gln77Arg) variant.

Purpose: We report our experience of diagnosing and managing metastatic adenocarcinoma of the lungs with primary manifestation to the iris and the ciliary body with the purpose to raise clinical suspicion for systemic malignancy in the presence of undetected ocular mass along with other ocular manifestations.Observations: An 82‐year‐old male presented with a deterioration of vision and intense pain in the right eye since the day before. With his right eye, he suddenly discerned hand movements only. Intraocular pressure in the right eye was increased. Slit–lamp biomicroscopy revealed a ciliary injection and hemorrhagic mass overlying the temporal half of the iris. The L‐9 ultrasound biomicroscopy (UBM) scan documented the tumor completely infiltrating the iris and the ciliary body. We suspected a metastatic eye lesion. CT chest imaging showed a solid expansive formation of the right lung. At the Oncology Department, a fine needle aspiration biopsy was performed under the control of MSCT, which confirmed lung adenocarcinoma.Conclusions and Importance: Although very rarely, pathological changes in the uvea may indicate a metastatic occurrence that needs to be considered in the differential diagnosis. It is important to undergo a wide ophthalmological examination, which in this case included a standardized A‐scan echography and UBM, which confirmed the suspicion of a tumor lesion, followed by cooperation with other medical professionals in order to discover a primary diagnosis.