Archive for May, 2012
Philipp Eberwein, MD ; Daniel Böhringer, MD; Johannes Schwartzkopff, MD; Florian Birnbaum, MD; Thomas Reinhard, MD
To present the technique and report the results of up to 36 months after allogenic central penetrating limbo-keratoplasty in conjunction with conjunctivoplasty, mitomycin C (MMC), and amniotic membrane (AM) transplantation in patients with bilateral limbal stem cell deficiency (LSCD).
Retrospective, consecutive subject cohort study.
Case records of 20 eyes from 20 patients who presented with bilateral LSCD due to aniridia, chemical/thermal burn, cicatrizing pemphigoid, and chronic ocular surface inflammation and who were treated at the University Eye Hospital, Freiburg.
All eyes were treated with central limbo-keratoplasty in conjunction with conjunctivoplasty, MMC, and AM. There were 20 human leukocyte antigen-typed allolimbal transplants from cadaveric donors. All patients received systemic immunosuppression with mycophenolate mofetil or cyclosporine A.
Main Outcome Measures
Surgical success was measured by the duration for which a healthy corneal epithelium was maintained. Visual success was measured by an improvement in visual acuity (VA) in the eye during follow-up and directly correlated with central clear graft survival.
The follow-up period was up to 34 months (mean, 20 months; median, 22.4 months). Mean VA, measured in decimal fractions, increased from 0.029 (∼20/400; median, 0.005; first quartile 0.005; third quartile 0.005) before surgery to 0.281 (20/70; median, 0.2; first quartile 0.04; third quartile 0.55) after surgery. Healthy corneal epithelium showing survival of limbal stem cells was observed in 14 eyes (70%) during complete follow-up.
Penetrating limbo-keratoplasty with conjunctivoplasty, MMC, and AM transplantation is a promising new surgical technique for improving vision and conjunctivalization in patients with severe bilateral LSCD necessitating allogenic transplants.
Jack Parker; Martin Dirisamer, MD; Miguel Naveiras, MD; Win Hou W. Tse; Korine van Dijk, BSc; Laurence E. Frank, PhD; Lisanne Ham, MSc; Gerrit R.J. Melles, MD, PhD
To determine the clinical outcomes of isolated Descemet membrane transplantation (ie, Descemet membrane endothelial keratoplasty [DMEK]) in phakic eyes.
Tertiary referral center.
Phakic eyes from a larger group of consecutive eyes that had DMEK for Fuchs endothelial dystrophy were examined. The examination included corrected distance visual acuity (CDVA), subjective and objective refractions, endothelial cell density (ECD), and intraoperative and postoperative complications at 1, 3, and 6 months.
The study enrolled 52 phakic eyes from a group of 260 DMEK eyes. Of the phakic eyes, 69% reached a CDVA equal to or better than 20/40 (≥0.5) within 1 week and 85% reached equal to or better than 20/25 (≥0.8) at 6 months. Compared with an age-matched control group of pseudophakic eyes, phakic eyes had a similar visual rehabilitation rate, final visual outcome, mean ECD at 6 months (1660 cells/mm2 ± 470 [SD]), minor hyperopic shift (+0.74 diopter), and graft detachment rate (4%). Visual acuity equal to or better than 20/13 (≥1.5) was limited to phakic eyes, suggesting better optical quality with the crystalline lens in situ. Temporary mechanical angle-closure glaucoma due to air-bubble dislocation behind the iris was the main complication (11.5%). Two eyes (4%) required phacoemulsification after DMEK.
In phakic eyes, DMEK may give excellent visual outcomes without an increased risk for complications. Visual acuities equal to or better than 20/13 (≥1.5) may indicate that the almost anatomic repair after DMEK is associated with near perfect optical quality of the transplanted cornea.
Basu, Sayan MBBS, MS; Reddy, Jagadesh C. MBBS, MS; Vaddavalli, Pravin K. MBBS, MS; Vemuganti, Geeta K. MD; Sangwan, Virender S. MBBS, MS
Purpose: To address the controversial issue of whether the occurrence of corneal hydrops adversely affects the fate of subsequent penetrating keratoplasty (PK), this study compared the long-term outcomes of PK in keratoconic eyes with resolved corneal hydrops with those without prior corneal hydrops.
Methods: This was a retrospective chart review of 102 eyes of 102 patients with keratoconus who underwent PK. The primary outcome measure was endothelial rejection–free allograft survival and the secondary outcomes were vision, postoperative complications, and histopathologic findings of corneal buttons obtained during PK.
Results: The mean follow-up after PK was 5.5 ± 3.3 years. The Kaplan–Meier endothelial rejection–free allograft survival at 1 and 5 years post-PK were 93.7% ± 4% and 82.6% ± 7%, respectively, in 32 eyes with hydrops and 100% and 98% ± 2%, respectively, in 70 eyes without hydrops (P = 0.04). Multivariate analysis showed that the risk of endothelial rejection episodes was greater in eyes with longer duration of corneal hydrops (P = 0.019) and coexistent ocular allergy (P = 0.012). All rejection episodes were reversed medically and only 1 allograft failed because of postoperative endophthalmitis. More than 90% of eyes achieved a visual acuity of better than 20/40. Common postoperative complications were cataract and graft infiltrate. Histopathology in cases of resolved hydrops after intracameral gas showed unique compression artifacts like folding and burial of the broken ends of Descemet membrane in the stroma.
Conclusions: Although endothelial rejection episodes are more common in eyes with resolved corneal hydrops, long-term allograft survival and visual results after PK in eyes with keratoconus are excellent, irrespective of prior corneal hydrops.
Sarnicola, Vincenzo MD; Toro, Patricia MD; Sarnicola, Caterina; Sarnicola, Enrica; Ruggiero, Andrew PhD
Purpose: To determine corneal graft survival rates up to 10 years in a large consecutive series of deep anterior lamellar keratoplasties (DALKs).
Methods: A retrospective, consecutive, noncomparative cases series of DALK procedures in a total of 806 eyes of 711 patients with stromal diseases and healthy endothelium performed between 2000 and 2009. Inclusion criterion was surgery performed by a single surgeon (660 eyes), with at least 6 months of follow-up. Graft survival was analyzed using the Kaplan–Meier method. Endothelial loss was analyzed with the Gaussian distribution and the χ2 methods. Follow-up time, and preoperative and postoperative endothelial cell density (ECD) were considered in the analyses.
Results: Six hundred sixty eyes of 502 patients met the entry criteria. Mean length of follow-up was 4.5 years (range, 0.5–10 years). We report an average graft survival rate of 99.3% (range, 98.5%–100%); 3 eyes (0.45%) experienced graft failure and 1 eye (0.15%) developed late endothelial failure because of an intraoperative complication. Predominant indications for DALK in this series were keratoconus (74%), postherpetic keratitis scarring (15%), and corneal stromal opacities of different etiology (11%). Endothelial loss from preoperative levels averaged 11% (range, 10%–13%) at 6 months through 10 years after DALK. ECD was unchanged between 6 months postoperatively and the last follow-up visits.
Conclusions: DALK is a successful form of transplantation in stromal corneal disorders with healthy endothelium, with higher long-term graft survival rates and stable ECD 6 months postoperatively. DALK survival rates do not vary significantly over time.
Riss, Stephan MD; Heindl, Ludwig M. MD; Bachmann, Bjoern O. MD; Kruse, Friedrich E. MD, PhD; Cursiefen, Claus MD, PhD
Purpose: To describe the clinical results of Pentacam-based big bubble deep anterior lamellar keratoplasty (DALK) to achieve an intended 90% depth of initial lamellar trephination.
Methods: Fifty consecutive eyes of 50 patients with keratoconus, keratoglobus, and anterior stromal scars were included. DALK was performed with the big bubble technique using a 90% intended depth for initial lamellar trephination based on preoperative pachymetry by Pentacam. Main outcome measures were success of surgery, best spectacle–corrected visual acuity, endothelial cell count, refractive astigmatism at 12-month follow-up, and rate of intra- and postoperative complications.
Results: In 84% of the patients (n = 42), Pentacam-based big bubble DALK could be performed successfully. Successful big bubble formation could be achieved in 80% of the patients (n = 34). In case of macroperforation (n = 8), surgery was converted to standard penetrating keratoplasty representing a conversion rate of 16%. Intraoperative microperforation (n = 5) could be handled by an intracameral air injection at the end of operation with successful completion of the lamellar procedure. No allograft rejection was observed. Best spectacle–corrected visual acuity improved from 20/125 ± 20/160 preoperatively to 20/40 ± 20/80 at 12-month follow-up. Endothelial cell count was 2102 ± 318 cells per square millimeter preoperatively and 1735 ± 420 cells per square millimeter at 12-month follow-up. Refractive astigmatism was 7.09 ± 3.13 diopters preoperatively and decreased to 4.13 ± 2.41 diopters.
Conclusion: Pentacam-based big bubble DALK using a 90% intended depth of initial lamellar trephination seems to be a safe and effective procedure for anterior corneal stromal disorders such as keratoconus. We suggest that Pentacam-based depth assessment allows for reliably deep initial preparation and may allow more successful bubble formation in DALK surgery.
Heitor de Paula, Fernando MD; Kamyar, Roheena MD; Shtein, Roni M. MD, MS; Sugar, Alan MD; Mian, Shahzad I. M
Purpose: To evaluate outcomes of endothelial keratoplasty (EK) without Descemet membrane stripping for treatment of failed penetrating keratoplasty (PKP).
Methods: Retrospective cohort study of all eyes that underwent EK without Descemet membrane stripping for failed PKP at one institution between May 2008 and June 2010, with follow-up to 12 months. Main outcome measures were best-corrected visual acuity (BCVA), dislocation rate, and graft failure.
Results: Twenty-two eyes of 22 patients underwent non-Descemet stripping EK with a mean follow-up of 8.8 months (±3.41; range, 3–12 months). The mean preoperative BCVA was logarithm of the minimum angle of resolution (logMAR) 1.43 (±0.72; range, 0.3–3; Snellen, 20/537; N = 22). The mean postoperative BCVA was logMAR 0.97 (±0.88; range, 0–3; N = 21) at 1 month, 0.76 logMAR (±0.74; range, 0.1–3; N = 21) at 3 months, 0.75 (±0.77; range, 0–3; N = 17) at 6 months, and logMAR 0.55 (±0.38; range, 0.18–1; Snellen, 20/70; N = 9) at 1 year. Eight eyes (36.6%) had graft dislocations requiring one rebubbling procedure in 6 of 8 eyes and 2 rebubblings in the other 2 eyes. All grafts were successfully reattached. Graft failure occurred in 2 of 22 eyes (9%), with 1 eye (5%) undergoing repeat EK and 1 eye (5%) undergoing PKP.
Conclusions: EK without Descemet membrane stripping is an effective option for management of eyes with failed PKP and may be a preferable alternative to a repeat PKP.
Maccheron, Luke J. BMedSci, MBBS, FRANZCO; Daya, Sheraz M. MD, FACP, FACS
Purpose: To describe the use of crescentic corneal lamellar wedge resection and autolamellar dissection for the correction of pellucid marginal degeneration (PMD), and to assess its effectiveness in improving uncorrected visual acuity (UCVA), best-corrected visual acuity (BCVA), astigmatism, corneal topography, and contact lens or spectacle tolerability.
Methods: The setting was a specialist referral corneal surgery center, United Kingdom. A retrospective review was performed of all patients who underwent a corneal wedge resection for PMD at our institutions. All patients had progressive deterioration of BCVA, increased astigmatism, and intolerance to contact lens wear. The irregular corneal shape with ectasia was detected clinically and confirmed by Orbscan tomography. A crescentic wedge of ectatic corneal tissue was excised in each case, the extent of which was judged both clinically and by Orbscan. Complete host deep lamellar dissection (limbus to limbus) was performed in 3 cases and partial host lamellar dissection in 3 cases to enable closure by mobilizing the host anterior lamellar cornea. Mersilene 10-0 (Ethicon, Somerville, NJ) sutures were used and adjusted to achieve a 90-degree shift in the axis of astigmatism.
Results: Seven eyes of 6 patients had wedge resections performed by 1 surgeon (S.M.D.). The patients were followed for a mean of 10.7 months (SD, 9.2; range, 1–25 months). The eyes of patients with >1 month of follow-up had improved UCVA and BCVA. Four of 5 eyes of patients with >2 months of follow-up had a BCVA of 6/12 or better. Four patients were able to manage with improved visual acuity in spectacles, and 1 patient chose to wear contact lenses to achieve 6/7.5. One patient with only 6 months of follow-up had a UCVA of 6/7.5. The average reduction in keratometric cylinder for cases with >2 months of follow-up was 9.1 diopters (SD, 5.3; range, 3.1–16.3 diopters).
Conclusions: Corneal wedge resection with and without lamellar dissection is an effective surgical intervention for corneal ectasia in PMD and avoids allogeneic transplantation by way of a large penetrating or lamellar keratoplasty. The technique has a low intraoperative complication rate and gives improved UCVA, BCVA, keratometric cylinder, and spectacle or contact lens tolerance.
Marie-Claude Robert, Krystel Moussally, Mona Harissi-Dagher
Endophthalmitis remains one of the most damaging and challenging complications following Boston keratoprosthesis type 1 (KPro) surgery. The authors reviewed the literature from 2001 onward to identify cases of endophthalmitis following KPro surgery and present an additional case of endophthalmitis in a patient with Stevens Johnson syndrome. The prevalence of endophthalmitis between 2001 and 2011 was 5.4%. Gram-positive bacteria are the most common agents responsible for endophthalmitis in this patient population while gram-negative bacteria and fungi are emerging pathogens. Risk factors for endophthalmitis include preoperative diagnosis of cicatricial disease and postoperative infectious keratitis, glaucoma drainage device erosion and non-compliance with antibiotic prophylaxis. Additional studies on the prevention and treatment of endophthalmitis are required to improve the overall prognosis of these patients.
Allen O. Eghrari, Elyse J. McGlumphy, Benjamin W. Iliff, Jiangxia Wang, David Emmert, S. Amer Riazuddin, Nicholas Katsanis, John D. Gottsch
To investigate the clinical and genetic features of late-onset Fuchs corneal dystrophy (FCD) on Tangier, an island in the Chesapeake Bay with an isolated population of approximately 500 individuals.
Observational, cross-sectional study.
A total of 156 individuals born to inhabitants of Tangier Island volunteered to undergo ophthalmic evaluation. Medical history was ascertained prior to examination. All participants underwent anterior segment examination with slit-lamp biomicroscopy. Retroillumination photographs were acquired from affected individuals and the disease severity was compared with individuals from large families ascertained previously. Genomic DNA samples were investigated for the presence of the recently identified risk allele rs613872, an intronic variant of TCF4.
Of the 148 examined individuals who were at least 30 years of age, 32 showed the classical symptoms of late-onset FCD (21.6%), providing a minimum prevalence of 11% among individuals over the age of 50 years. Severity was significantly lower compared to 51 cases from unlinked families, among individuals either 50 to 70 or above 70 years of age (P = .05 and P = .01, respectively). Retroillumination photography analyses were suggestive of mild severity when compared with the disease phenotype associated with FCD1- and FCD2-linked families. The rs613872 variant was associated with a higher affectation rate (P = .01), while the wild-type allele was correlated with a higher proportion of subclinical disease (P = .01).
In this study population in Tangier, late-onset FCD manifests clinically with a mild phenotype and increased prevalence. The rs613872 variant correlates with increased affectation and a clinical disease phenotype.
Theofilos Tourtas , Kathrin Laaser, Bjoern O. Bachmann, Claus Cursiefen, Friedrich E. Kruse
To evaluate visual outcome and endothelial cell survival after Descemet membrane endothelial keratoplasty (DMEK) in comparison with Descemet stripping automated endothelial keratoplasty (DSAEK).
Single-center, retrospective, consecutive case series.
Thirty-eight eyes of 38 consecutive patients undergoing DMEK, who completed a 6-month follow-up, were compared with 35 eyes of 35 consecutive patients undergoing DSAEK for Fuchs endothelial dystrophy or pseudophakic bullous keratopathy. Main outcome measures included best-corrected visual acuity (in logarithm of the minimal angle of resolution [logMAR] units) and endothelial cell density within a 6-month follow-up.
Best-corrected visual acuity increased from 0.70 ± 0.48 logMAR and 0.75 ± 0.32 logMAR before surgery to 0.21 ± 0.14 logMAR and 0.48 ± 0.19 logMAR 3 months after DMEK and DSAEK (P < .001), respectively, and to 0.17 ± 0.12 logMAR and 0.36 ± 0.15 logMAR 6 months after DMEK and DSAEK (P < .001), respectively. Endothelial cell density decreased from 2575 ± 260 cells/mm2 and 2502 ± 220 cells/mm2 before surgery to 1498 ± 244 cells/mm2 and 1778 ± 420 cells/mm2 3 months after DMEK and DSAEK (P < .001), respectively, and to 1520 ± 299 cells/mm2 and 1532 ± 495 cells/mm2 6 months after DMEK and DSAEK (P = .483), respectively. Central corneal thickness decreased from 652 ± 92 μm before surgery to 517 ± 45 μm 6 months after DMEK, and from 698 ± 137 μm before surgery to 618 ± 66 μm 6 months after DSAEK.
DMEK provided faster and more complete visual rehabilitation when compared with DSAEK. However, there were no significant differences concerning endothelial cell survival within a 6-month follow-up.