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Moderator
Namrata Sharma, MD, FRCSEd, FRCOphth
Panelists
Samar A. Alswailem, MD; Samina F Zamindar, MS, DOMS
Viewing Papers
Expand a paper title to the right to view the paper abstract and authors. Use the video link to jump to that poster in the session.
Presenting Author
Sam Garg, MD
Co-Authors
Ehsan Sadri (MD), Jennifer Loh (MD), John Hovanesian (MD), Laura Periman (MD), Neel Desai (MD)
Purpose
To assess the safety and feasibility of repeat treatments on the conjunctiva using a novel topical ocular cooling device under development for the treatment of chronic ocular surface pain (COSP).
Methods
Two supratherapeutic repeat cold treatments were delivered 42 days apart to the ocular surface of five Dutch Belted rabbits and three Yucatan minipigs using the novel topical ocular cooling device. The fellow eye received a room temperature treatment of the same duration as a control. Clinical signs, intraocular pressure (IOP), and behavior were monitored throughout the study. Histological evaluation of all eyes was performed 54 days after the retreatment.
Results
No treatment-related adverse events or abnormalities were reported. All animals exhibited normal behavior, normal ocular function, and normal IOP at all assessments. Evaluation of ocular histology was normal for both treated and control eyes.
Conclusion
Repeated treatments using a novel topical ocular cooling device designed for COSP demonstrated adequate safety and tolerance in two different animal species.
Presenting Author
Yishay Weill, MD
Co-Authors
Sharon Braudo (MD), Elishai Assayag (MD), Adi Porat Rein (MD, MHA), David Zadok (MD), Anna Lisitsky (MD)
Purpose
To evaluate the long-term impact of ocular chemical injuries on corneal endothelial cells in eyes who initially presented with burn-induced corneal edema that resolved clinically on follow-up.
Methods
Patients with unilateral chemical burn and corneal edema on presentation, treated between January 2020 and June 2024 at the ophthalmology clinic of a tertiary medical center, were retrospectively included. Patients with bilateral injuries, prior ocular surgeries, corneal dystrophies, or less than three months of follow-up were excluded. Endothelial cell parameters, including endothelial cell density (ECD), coefficient of variation, hexagonality, average cell size and central corneal thickness (CCT), were assessed bilaterally using specular microscopy. Injured eyes were compared to their contralateral, unaffected eyes.
Results
Eight patients (16 eyes) were included, with a mean follow-up of 25.9?±?17.1 months. Injuries were caused by alkaline (62.5%) or acidic (37.5%) agents. At the last follow up, the mean ECD in injured eyes was significantly lower than in uninvolved eyes (956.25?±?137.5 vs. 2740.25?±?266.94?cells/mm�, P?
Conclusion
Chemical ocular injuries can result in significant and sustained corneal endothelial cell loss in patients who initially present with burn-induced corneal edema, even if the corneas later appear clinically clear. These findings emphasize the importance of long-term ECD monitoring and careful surgical planning in this population.
Presenting Author
Carolina L. Mercado, MD
Co-Authors
Michelle Kwon (PhD), Michelle Ratay (PhD), Lisa Nijm (MD, JD)
Purpose
To document patient characteristics, diagnostic tests, and treatment of dry eye disease (DED) in patients outside of the clinical trial setting, leveraging real-world evidence (RWE).
Methods
Retrospective cohort study using the American Academy of Ophthalmology IRIS® (Intelligent Research in Sight) Registry linked to pharmacy claims data. Patients were diagnosed with DED and initiated an index lifitegrast DED prescription therapy between Jan 1, 2017, and Dec 31, 2024.
Results
Study included 143,005 patients who initiated lifitegrast DED therapy (mean age, 61 y; 80% female). Ocular comorbidities included cataracts (41%), glaucoma (9%), and age-related macular degeneration (5%). Non-ocular included hyperlipidemia (45%), hypertension (43%), diabetes (21%), obstructive sleep apnea (11%), chronic obstructive pulmonary disease (6%) rheumatoid arthritis (6%) and SjÖgren's syndrome (6%). About 7% of eyes (n=19,654) had recorded tear film break-up time measurements, 2% (n=4877) had Schirmer's, and 11% (n=29,830) had tear osmolarity tests. Prior to index therapy, 11% of patients had received a prescription (predominantly topical cyclosporine 0.05%); 8% punctal plugs.
Conclusion
This large RWE study shows that patients with DED often have significant ocular and systemic comorbidities. Diagnostic testing remains underutilized, highlighting practice gaps and informing future strategies to improve diagnosis and treatment.
Presenting Author
Francis S. Mah, MD
Purpose
Despite high prevalence, dry eye and dry eye disease (DED) are often misunderstood, undertreated, and their impacts underestimated. To optimize surgical outcomes, minimizing DED signs and symptoms is key. This online survey sought to understand the prevalence, perceptions, and impact of DED in US adults.
Methods
US adults, including DED sufferers (those who often/always experience eye dryness and/or have been diagnosed by a healthcare professional) completed an online survey administered by The Harris Poll. Harris online poll sampling precision is measured using a Bayesian credible interval. Here, the sample data are accurate to within 3.0 with a 95% confidence interval (CI), with statistically significant differences between the DED sufferers and non-sufferers at the 95% CI. This credible interval was wider among population subsets analyzed. 2,003 adults were recruited, including 461 self-identified dry eye sufferers.
Results
Among non-sufferers, 74% reported related symptoms (tired eyes, light sensitivity, redness) but only 15% associated these symptoms with dry eye. 70% said they did not know much about preventing or treating dry eye and 44% did not know untreated dry eye can lead to other problems including vision loss. Among dry eye sufferers, 33% had never visited an eye care professional (ECP) for dry eye and 52% of sufferers simply tolerated symptoms despite 81% being constantly aware of their eyes and 67% reducing/stopping activities like screen time and reading. For those sufferers who did see an ECP about their dry eye, 67% waiting for more than 6 months to do so (31% over 2 years).
Conclusion
Dry eye remains largely undertreated, causing daily discomfort and permitting potential worsening. US ECPs have an opportunity to better engage and educate their patients to help address this. For the ocular surgeon, ensuring patients recognize how to mitigate the effects of dry eye may improve pre- and post-surgery ocular health.
Presenting Author
Karl G. Stonecipher, MD
Purpose
To analyze a subset of dry eye disease patients with meibomian gland dysfunction who had failed both pharmacologic and interventional treatments over multiple attempts and multiple platforms.
Methods
This prospective, open-label, single site, single surgeon clinical trial analyzed data from 20 eyes of 10 patients who presented with severe Ocular Surface Index Disease Scores (OSDI average 46.7) and TFOS Grade 3 or meibomian glands that could not be expressed manually (MGE). Lipid layer levels (LLL) as measured by the Lipiview device were on average 61.75 mm for the group prior to intervention.
Results
This prospective, open-label, single site, single surgeon clinical trial analyzed data from 20 eyes of 10 patients who presented with severe Ocular Surface Index Disease Scores (OSDI average 46.7) and TFOS Grade 3 or meibomian glands that could not be expressed manually (MGE). Lipid layer levels (LLL) as measured by the Lipiview device were on average 61.75 mm for the group prior to intervention.
Conclusion
Opitvize is a treatment for MGD using Blephex for lid margin exfoliation, followed by an electrical current applied via a patient interface. Finally, MGE is performed. This series (N-20) of extreme cases shows significant improvement in as little as one treatment. The author will discuss the treatment population and potential.
Presenting Author
Gilles Lesieur, MD
Purpose
This study evaluates the safety and efficacy of JETT MEDICAL, an electroporation-based device, for Dry Eye Disease (DED). Electroporation transiently increases cell membrane permeability, promoting hydration and nutrient exchange, with potential benefits for tear film stability and ocular surface health.
Methods
This prospective, single-center study in France enrolled adults with moderate to severe DED and Ocular Surface Disease Index (OSDI) >13 or 5-item Dry Eye Questionnaire (DEQ-5) >6, unresponsive to conventional therapy. Exclusion criteria were infection, recent surgery, or contact lens wear. Patients received three weekly sessions with the JETT MEDICAL electroporation device using a silver applicator and gel conduction. Primary endpoints were OSDI and DEQ-5. Secondary endpoints were Tear Break Up Time (TBUT), Interblink Interval (IBI), Ocular Protection Index (OPI), Schirmer test, meibography, ocular surface staining, and epithelial mapping by Optical Coherence Tomography (OCT).
Results
Significant improvements were observed in OSDI and DEQ-5 scores. Mean DEQ-5 decreased from 12.2 (SD 3.4) at baseline to 9.7 (SD 3.59) at day 7 and 8.7 (SD 3.95) at 1 month (p<0.001). Median OSDI improved from 37.05 (IQR 24.43) to 18.75 (IQR 30.73) at day 7 and 21.52 (IQR 22.9) at 1 month (p=0.005). Meibomian gland atrophy decreased from 30.0% (IQR 12.5) to 27.0% (IQR 14.5) (p=0.002). No significant changes were found in TBUT, IBI, OPI, Schirmer test, or corneal/conjunctival staining (p=0.952). Epithelial mapping showed increased epithelial thickness in central, superior, and inferior zones, though not statistically significant (p=0.582).
Conclusion
JETT MEDICAL is a promising non-invasive option for Dry Eye Disease, providing significant symptom relief and early signs of ocular surface improvement. While tear film results remain inconclusive, epithelial and glandular changes may indicate efficacy. Larger, longer studies are needed.
Presenting Author
Darrell E. White, MD
Co-Authors
Rahul Tonk (MD, MBA), Nandini Venkateswaran (MD), Dagny Zhu (MD), Neel Desai (MD), Parag Majmudar (MD)
Purpose
To assess the pre-clinical safety (including corneal healing after iatrogenic corneal abrasion) of a novel topical ocular cooling device under Good Laboratory Practice (GLP) guidelines in New Zealand White (NZW) rabbits.
Methods
Two studies in NZW rabbits were performed to evaluate ocular safety. In the first study, 5 rabbits were treated with the device on one eye, and safety was assessed up to 56 days post-treatment. In the second study, 3 rabbits underwent the novel topical cooling on only one eye and 14 days later a 3mm corneal epithelial defect was created on each eye to evaluate the impact of the treatment on corneal re-epithelialization. In both studies, safety was assessed using clinical ophthalmic exams (including corneal fluorescein staining), tear production (Schirmer's I/II), intraocular pressure (IOP), and terminal histopathology were performed.
Results
The cold surface treatments in both studies were well tolerated. Only benign, transient, anterior findings were noted immediately post-procedure. Shirmer's tear production tests I and II were normal, and IOP remained normal as well. Corneal re-epithelization in the second study was unaffected by the device treatment, with complete epithelial recovery in both treated and untreated eyes by 48 hours.
Conclusion
A single treatment with a novel ocular cooling device is well tolerated, safe, and does not impair corneal re-epithelialization. This data supports continued clinical development.
Presenting Author
Marguerite B. McDonald, MD
Co-Authors
James Katz (MD), Alice Epitropoulos (MD, FACS), Preeya Gupta (MD), Bonnie An Henderson (MD), Anat Galor (MD, MPH)
Purpose
To assess long-term clinical safety, efficacy, and patient satisfaction from a double-masked, randomized, placebo-controlled study of a novel ocular surface cooling device used to treat chronic ocular surface pain (COSP).
Methods
Patients (n=20) who received a unilateral treatment with the novel ocular surface cooling device were recalled for an extended follow up visit one year after the treatment date. Clinical safety measures included corneal sensitivity, intraocular pressure, gonioscopy, and a slit lamp exam for limbal stem cell deficiency. Efficacy was evaluated using the validated chronic ocular pain questionnaire (COP-Q). Subject satisfaction was assessed using four self-narrative questions. The questions included overall satisfaction with the treatment, willingness to refer the treatment to family and friends, desire to have the fellow eye treated, and desire to have the study eye re-treated.
Results
The majority of subjects believed that the cooling treatment helped with their COSP symptoms and provided open-ended responses such as "Yes, the treatment was helpful and showed marked reduction in eye pain vs the other non-treated eye". Furthermore, more than half the subjects would refer the treatment to their family and friends. The desire to have their fellow eye treated, as well as their study eye re-treated, was reported in most subjects. A least two of the subjects reported a continued durable effect of the treatment at one year. Mean COP-Q eye pain severity scores (0-10) at one year post-treatment were 2.1 units lower than baseline.
Conclusion
One-year post-treatment safety assessments showed no signs of increased IOP, limbal stem cell deficiency, corneal staining, or any other adverse effects. These results suggest that patients undergoing treatment with a novel ocular surface cooling device for chronic ocular surface pain (COSP) experience a high rate of long-term satisfaction.
Presenting Author
Rachana P Shah, MBBS, MS
Co-Authors
Zeenal Dabre (MBBS)
Purpose
The aim of the present study was to understand the effects of hormonal imbalance in patients with polycystic ovary syndrome (PCOS) on dry eye signs and symptoms and the effect of hormonal treatment on these dry eye parameters.
Methods
This retrospective study included 97 eyes of 51 patients. 16 patients (n=31 eyes) had PCOS, 25 patients (n= 46 eyes) had polycystic ovaries (PCO) and 10 patients (n=20 eyes) were healthy controls. Data regarding ocular surface disease index (OSDI), tear break-up time (BUT), schirmer's test, corneal staining, meibomian gland expression grade were incorporated into the study. Blood test results of luteinizing hormone (LH), follicle stimulating hormone, Estradiol, progesterone, testosterone, dehydroepiandrosterone sulfate, neutrophil to lymphocyte ratio and platelet to lymphocyte ratio were also included in the analysis. Single factor ANOVA test was used to compare the three groups.
Results
PCOS group (31.67 ± 25.25) had higher (p < 0.05) OSDI compared to PCO (12.56 ± 23.45) and the control group (10.68 ± 13.56). The BUT was faster in the PCOS group (8.55 ± 6.32) compared to PCO (14.10 ± 6.15) and the control group (15.32 ± 4.32). Total corneal staining was higher in the PCOS compared to PCO and control group (p<0.05). There was no difference in schirmer's between the two groups (p>0.05). The PCOS group had higher levels of LH, testosterone and estradiol levels. Inverse correlation was found between testosterone levels and BUT (p<0.05). All patients with PCOS were treated with systemic anti-androgen therapy. There was an improvement in OSDI (?= - 10.34 ± 6.28 ) and BUT (?= + 2.25s ± 4.25 ) after 6 months of hormonal therapy in patients with PCOS.
Conclusion
Dry eye symptoms in patients with PCOS could be related to their hormonal imbalance. Correction of the hormonal levels could result in symptom relief in these patients.
Presenting Author
Mayank A. Nanavaty, PhD
Co-Authors
David Lockington (FRCOphth, PhD), Radhika Rampat (MBBS, FRCOphth), Darren Shu Jeng Ting (FRCOphth, PhD), Elizabeth Yeu (MD), Emil Kurniawan (MBBS, MD, FRANZCO)
Purpose
Two-thirds of blepharitis cases are due to Demodex overgrowth causing Demodex blepharitis (DB), characterised by the presence of collarettes. DB remains underdiagnosed with limited burden data available. Here we examined DB prevalence, patient characteristics, treatment patterns, and healthcare resource use in NHS public specialist centres.
Methods
Aurora was a cross-sectional, retrospective audit across five NHS public specialist centres in the UK. Adults (?18 years) attending appointments in June 2025 and undergoing slit-lamp examination were included, excluding those with active ocular infections or lid abnormalities. At each clinic,100 consecutive patients were screened, with chart reviews of DB-positive cases covering the preceding 3 years. Patients were stratified into DB-positive (mild: 1-10 collarettes; moderate/severe: >10 collarettes) and non-DB (no collarettes). Symptom frequency was rated as occasionally, frequently or all the time. Data were analysed using descriptive statistics and mixed effect regression models.
Results
Of 500 patients, 57.8% had DB; 24.1% were moderate/severe DB patients. Independent predictors of DB included rosacea (aOR 9.6, 95% CI 2.2 to 42.8, p=0.003), glaucoma (aOR 7.4, 95% CI 1.1-50.1, p=0.041), and older age (aOR 1.029, 95% CI 1.0-1.1, p=0.005). The majority of DB patients (90.2%) reported symptoms, which increased in frequency in the moderate/severe DB group. Severe DB was linked to 2.5-fold higher odds of greater symptom frequency (aOR 2.51, 95% CI 1.3-4.8, p=0.005). Artificial tears (84%), other lid hygiene (38.5%) and topical steroid drops (38.5%) were the most common treatments.
Conclusion
To our knowledge, Aurora is the first study to explore DB burden in a UK public specialist eye care setting. DB patients show symptom burden and multiple ocular comorbidities, while receiving non-Demodex-specific treatments and experiencing unresolved symptoms, signalling a high unmet need.
Presenting Author
Uma Yogesh Thigale, MBBS, MS
Co-Authors
Ugur Tunc (MD), Felipe Barandiaran (BSc), Meltem Yashar (MD), Esen Akpek (MD), Sezen Karakus (MD)
Purpose
To evaluate the longitudinal stability and clinical significance of early SjÖgren's antibodies (anti-SP1, anti-CA6, anti-PSP) in dry eye patients with suspected SjÖgren's disease.
Methods
This prospective longitudinal cohort study included 65 adult dry eye patients at the Wilmer Eye Institute, Johns Hopkins University, between April 2014 and October 2022, with prior testing with the SjÖ� panel for early Sjogren disease antibodies. Patients were invited for a follow-up visit (July 2021-October 2023) and underwent repeat evaluation, Ocular Surface Disease Index questionnaire and standardized ocular surface assessment, including Schirmer testing and ocular surface staining. Longitudinal changes in early SjÖgren's antibodies, evidence of isotype switching, development of SjÖgren's disease, changes in Schirmer test results and ocular staining score were assessed.
Results
Over a mean follow-up of 4.37±2.14 years, antibody status was unstable: 28 positive patients at baseline became negative & 22 negative patients became positive, with no evidence of isotype switching. No patient newly developed anti-SSA antibodies or newly met classification criteria for SjÖgren's. The prevalence of Schirmer ?5 mm increased from 38% to 59% (p=0.004), but that of OSS ?5 was unchanged (45% vs 45%, p=0.83). Baseline antibody positivity was associated with higher odds of Schirmer ?5 mm at follow-up (OR 6.99, 95% CI, p=0.039). Both baseline & follow-up antibody positivity predicted OSS ?5 (OR 6.2, 95% CI 1.6-23.9, p=0.008; OR 4.1, 95% CI 1.1-15.5, p=0.036).
Conclusion
Early SjÖgren's antibodies (SP1, CA6, PSP) fluctuate randomly over time, without evidence of isotype maturation or predictive value for SjÖgren's disease development. Although antibody positivity was associated cross-sectionally with Schirmer & ocular surface staining, the lack of longitudinal stability limits their diagnostic & monitoring utility.
Presenting Author
Kishan Avaiya, BSc
Co-Authors
Mohammad Soleimani (MD)
Purpose
To describe a rare case of severe vitamin A deficiency manifesting as bilateral keratomalacia years after malabsorptive bariatric surgery and review the literature on its ocular complications and outcomes.
Methods
A case report and literature review were conducted. Clinical details of a woman in her early 40s presenting with acute bilateral vision loss nine years after biliopancreatic diversion with duodenal switch bariatric surgery were analyzed. Ophthalmic examination, laboratory studies, and treatment course were documented. Literature review was performed using PubMed to identify reports of vitamin A deficiency and ocular sequelae following bariatric surgery.
Results
The patient exhibited Bitot's spots and progressive keratomalacia with laboratory-confirmed deficiencies in vitamins A, D, E, K1, and albumin due to noncompliance with vitamin supplementation and bariatric follow-up. Treatment with high-dose intramuscular vitamin A and total parenteral nutrition led to significant visual recovery and resolution of keratomalacia over two months since hospital discharge. Literature review revealed few reported cases, underscoring delayed presentation and risk of severe ocular morbidity.
Conclusion
Vitamin A deficiency is a rare but severe complication of malabsorptive bariatric surgery that can manifest years post-procedure, particularly with poor adherence to nutritional guidelines. Prompt recognition and aggressive multimodal supplementation are necessary to reverse ocular pathology and prevent permanent vision loss in this population.
Presenting Author
Amber Y Kwon, BA
Co-Authors
Moonjung Choi (MD), Jose Giraldo (MD), Olivia Lee (MD)
Purpose
To compare ocular signs and symptoms of ocular Graft Versus Host Disease (GVHD) and non-GVHD dry eye.
Methods
Twenty-six ocular GVHD and 23 DED patients were examined for their tear break-up time (TBUT), ocular surface staining with Oxford scale, Schirmer test, and meibum quality. The patients' symptoms were assessed using Ocular Surface Disease Index (OSDI) questionnaire. The Matrix Metalloproteinase-9 (MMP-9) immunoassay was graded on a 0-8 scale, with band color intensity referenced against previously reported concentration ranges (Lee J, et al. 2021). Infrared meibography was used to assess meibomian gland dropout.
Results
The ocular GVHD patients had significantly higher ocular surface staining score (2(2-3)) compared to non-GVHD dry eye patients (0.5(0-1)) (p<0.001). Ocular GVHD patients also had lower Schirmer test values (4.42 +/- 3.98mm) than dry eye patients (7.05 +/- 3.91mm) (p=0.033). The MMP-9 positivity grade was higher in ocular GVHD patients (6(4-7)) than dry eye patients (3(1-4)), however the difference was not statistically significant (p=0.055). Other parameters including TBUT, OSDI, meibum quality, and meibomian gland dropout did not show significant differences.
Conclusion
Ocular GVHD patients had worse ocular surface damage and decreased tear production compared to non-GVHD dry eye patients. This is likely to be due to the immunologic destruction of the ocular tissues in GVHD. Understanding the characteristic clinical features of ocular GVHD may help in diagnosing and providing guidance for effective treatment.
Presenting Author
Marguerite B. McDonald, MD
Purpose
To evaluate the long-term outcomes of using a dehydrated, decellularized basement membrane (Biovance) with a glueless, sutureless surgical technique in primary and recurrent pterygium surgery.
Methods
A retrospective case series of 34 eyes undergoing pterygium excision with a glueless, sutureless placement of a Biovance Ocular 3L decellularized basement membrane with mitomycin c. Patients were followed for 12 months. Recurrence was defined as fibrovascular tissue invading onto the cornea. Additional outcomes included surgical time, adverse events, and patient-reported healing. All procedures were performed by a single surgeon using a standardized technique.
Results
A total of 34 eyes from 33 patients underwent pterygium excision using dehydrated, three-layer decellularized basement membrane. Of the patients enrolled, 24 were men and 10 female. The average age was 52.8 with a range from 32 to 86 years. The average follow up was 394 days with a range of 174-668 days. All patients reported minimal post operative discomfort and the operative eyes were relatively quiet with minimal subconjunctival injection. There were no recurrences, pyogenic granuloma, infections, dellen, or melts reported.
Conclusion
In pterygium excision, decellularized basement membrane may contribute to faster, more comfortable recovery, improved cosmesis, and a reduced risk of recurrence, particularly when used with adjunctive mitomycin C.
Presenting Author
Michael Cheng, BSc
Co-Authors
Karanpreet Multani (MD), Ishan Bhanot (BSc, BA), Kamran Riaz (MD)
Purpose
To evaluate epithelial healing, visual outcomes, and ocular comfort following BrightMEM Anterior Keratoplasty (BMAK) in patients with anterior corneal pathology.
Methods
A retrospective review was performed of eyes undergoing BMAK at a tertiary center. Data collected included demographics, preoperative BCVA, indication for surgery, postoperative BCVA at latest follow-up, epithelial healing status and time to healing, presence of pain before and after surgery, need for additional procedures (e.g., amniotic membrane), and intra- and postoperative complications. Primary outcomes were epithelial healing and change in visual acuity. Secondary outcomes included pain relief, safety, and complications.
Results
25 eyes had BMAK, with a mean age of 62.7 ± 14.7 years. The main reason was limbal stem cell deficiency (LSCD) (32%), followed by LSCD with aniridia (12%), neurotrophic keratopathy (12%), and recurrent corneal erosion (8%). Surface improvement or stabilization occurred in 10 eyes (40%), with partial improvement in 6 eyes (24%). Complete epithelial healing occurred in 6 eyes (24%), while persistent defects were noted in 13 eyes (52%). 9 eyes (36%) had uncomplicated recoveries. Membrane-related issues occurred in 3 eyes (12%), and extra intervention was required in 2 eyes (8%). Visual acuity improved by ≥2 lines in 7 eyes (39%), stayed stable in 7 eyes (39%), and declined in 4 eyes (22%).
Conclusion
BMAK demonstrated the ability to stabilize the ocular surface in a subset of eyes with complex anterior corneal pathology. Although complete epithelial healing was not universal, many achieved surface stabilization with modest visual improvement and low complication rates. BMAK may serve as a useful adjunctive option for ocular surface disease.
