Faculty Bibliography

BACKGROUND:Lower lateral cartilage malposition is represented by anterior convexity of the lower lateral cartilage (LLC) dome with posterior pinch, as defined by Sheen and Constantian. This anatomic variation consists of cephalic, or upward and inward, rotation of lateral crura, particularly in bulbous tip patients. In most cases, "bulbous pinch" LLC is positioned toward the medial canthus, not laterally, so it is referred to as cephalic displacement. Accordingly, it is recommended to caudally displace cartilage in the majority of rhinoplasty cases in which variation is seen. OBJECTIVES/OBJECTIVE:The purpose of this paper is to measure the exact angle of lateral crura with fixed reference points on the face. METHODS:We drew and marked LLC contours and vertical/horizontal lines in 40 consecutive rhinoplasty cases. We then divided them into two groups: (1) bulbous pinch and (2) flat LLCs. The right- and left-sided LLC angles to midline and horizontal lines were measured and compared to assess whether there was any significant difference between the two subgroups. RESULTS:There was no significant difference between the angles of LLC rotation in the bulbous and flat LLCs groups, measured both vertically and horizontally. CONCLUSION/CONCLUSIONS:Based on our findings, although cephalic malposition of LLCs may be present in some patients but in the majority of cases the etiology of nasal lateral wall pinching is not cephalic displacement of lateral crura but most probably is due, rather, to severe convexity of the posterior and lateral crura. According to our findings, cephalic malposition is an uncommon anatomic variation of LLCs that has been reported at high frequency (60-70% of their rhinoplasty cases). This finding may help to correct this deformity into a normal anatomic configuration. LEVEL OF EVIDENCE IV/METHODS:This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

PURPOSE/OBJECTIVE:To present a case of new-onset, bilateral, rapidly progressive keratoconus induced by secondary hypothyroidism after radioactive iodine therapy during the sixth decade of life that was successfully treated with corneal cross-linking. METHODS:Case report and literature review. RESULTS:A 53-year-old woman with no ocular complaints but with a history of Graves' disease and thyrotoxicosis was treated with radioactive iodine therapy and oral levothyroxine for secondary acquired hypothyroidism 3 years prior. Initially, uncorrected distance visual acuity (UDVA) was 20/40 and corrected distance visual acuity (CDVA) was 20/25 in both eyes. Over the following 3 years, the patient developed worsening UDVA and CDVA, with increasing manifest astigmatism of greater than 7.00 diopters (D) in the right eye and 4.75 D in the left eye, with corneal thinning and focal steepening and was diagnosed as having bilateral progressive keratoconus. The patient underwent sequential corneal cross-linking with resultant postoperative CDVA of 20/20 and reduced maximum keratometry and manifest astigmatism in both eyes. The patient's thyroid levels were within normal limits throughout the clinical course. CONCLUSIONS:This case provides evidence of the relationship between keratoconus development and thyroid gland dysfunction. The pathophysiology of this relationship has yet to be completely elucidated, but elevated levels of thyroxine in the aqueous humor and tear film and thyroxine receptors in the cornea likely play a role. Screening topographies for patients with thyroid gland dysfunction may be of value for these higher risk patients. [J Refract Surg. 2018;34(5):351-353.].

PURPOSE/OBJECTIVE:To evaluate the effect of accelerated corneal cross-linking with photoactivated chromophore (PACK-CXL) as additional treatment for therapy-resistant infectious keratitis. METHODS:In this interventional cohort study, 20 patients (11 men and 9 women), aged 65.5 (interquartile range = 21.5-78.5) years, who were hospitalized for moderate-sized therapy-resistant bacterial corneal ulcers (11/20 microbiologically confirmed) were treated with hypoosmolar 0.1% riboflavin solution and Ultraviolet A (UVA) irradiation for 3 minutes at 30 mW/cm (5.4 J/cm) as additional therapy to standard antimicrobial treatment. RESULTS:We did not observe any adverse effects of accelerated PACK-CXL on the corneal stroma or limbus. The median ulcer size was 3.00 (2.63-4.50) mm, the median time to reepithelialization was 6.50 (5.00-18.0) days, and the mean hospitalization period was 8.5 ± 4.5 days. Tectonic keratoplasty became necessary in 1 patient (5%). CONCLUSIONS:Our results suggest that accelerated PACK-CXL may provide an antimicrobial effect similar to the 1 low-intensity, slow setting (30 minutes at 3 mW/cm) and may be used as additional treatment in moderate-sized therapy-resistant infectious keratitis.

PurposeTo investigate intraoperative anterior segment optical coherence tomography (AS-OCT) to compare pachymetry changes between two methods (group 1: speculum-on, group 2: speculum-off during riboflavin instillation stage) during corneal cross-linking /CXL) (9 mW/cm² for 10 min) in keratoconic patients.MethodsIn this interventional case series, 11 eyes (11 patients) in group 1 and 14 eyes (14 patients) in group 2 were enrolled. Pachymetry measurements by spectral domain OCT was performed at baseline, after epithelial removal, after 30 min of imbibition with riboflavin, and after UV irradiation. Repeated measures analysis of variance was used to compare the trend of changes in different stages of the procedure within and between two groups.ResultsThe corneal thinnest pachymerty (CTP) at baseline, after epithelial removal, 30 min of riboflavin instillation, and irradiation was 469.8±26.5, 438.0±27.1, 354.3±28.4, 367.1±31.8 microns in group 1 and 463.2±25.1, 438.0±27.1, 421.6±54.0, 386.9±34.0 microns in group 2, respectively. Group 1 showed a significantly greater decrease in the corneal pachymetry (P<0.001) during riboflavin instillation, while in group 2 a greater decrease in CTP was observed during the UV irradiation phase (P=0.002).ConclusionsUsing the intraoperative OCT, the speculum-off group had a more stable corneal pachymetry during riboflavin instillation time. Despite this, the effect was not lasting throughout the procedure; significant changes were noted in the corneal pachymetry at the end of operation in both groups; further highlighting the limitations imposed by corneal stromal shrinkage using isotonic dextran containing riboflavin solution for CXL.

PURPOSE/OBJECTIVE:) and accelerated treatment time (4 minutes) in eyes with progressive keratoconus using spectral-domain optical coherence tomography (SD-OCT) and to correlate focal epithelial and focal anterior curvature changes. SETTING/METHODS:Academic medical center in the United States. DESIGN/METHODS:Prospective case series. METHODS:Patients had anterior segment SD-OCT (RTVue-100) with focal stromal and epithelial measurements and Scheimpflug imaging before and 1, 3, 6, and 12 months after accelerated CXL. RESULTS:Twenty-seven eyes from 20 patients were evaluated. Before the accelerated CXL, the epithelium was thinnest in the inferior inner and outer temporal regions, whereas at 12 months postoperatively, the epithelium was significantly thinned in multiple inferior and nasal regions by 1.1 to 3.2 μm (P < .05, all measurements), with no significant changes from 6 to 12 months. Epithelial thickness standard deviation across the central 6.0 mm was significantly reduced by 3 months (1.4 μm, P = .09) and remained stable at 12 months (P = .009). Change in epithelial thickness was poorly correlated to change in anterior curvature (r = -0.035). CONCLUSIONS:Significant epithelial remodeling occurred after accelerated CXL in eyes with progressive keratoconus, with improved regularity across the central 6.0 mm, by 6 months after treatment. There was poor correlation between focal epithelial thickness and anterior curvature changes, with wide variability between patients. Establishing the pattern of epithelial remodeling after CXL might help optimize future custom treatment protocols.