Demographic and clinical profile,surgical outcome,and quality of life in patients who underwent bilateral lamellar corneal grafts

Purpose:Lamellar corneal grafts have revolutionized the management of corneal blindness by replacing only the disease specific corneal layers. To the best of our knowledge, there is no study in literature describing the outcomes of bilateral lamellar keratoplasty in the Indian population. The aim of this work was to study the demographic profile, surgical outcomes, and quality of life in patients who underwent bilateral lamellar keratoplasty and to assess the correlation between these three.Methods:An observational cross-sectional study was conducted on 47 patients who underwent bilateral deep anterior lamellar keratoplasty (DALK) (n = 31) or descemet stripping automated endothelial keratoplasty (DSAEK) (n = 16) with a minimum follow-up of 6 months after the second surgery. Demographic parameters were collected by interview, surgical outcomes by clinical examination, and quality of life by a questionnaire.Results:A total of 47 patients were evaluated, women 42.56%, (n = 20) and men 57.44% (n = 27) with 38.3% being in 18–30 years age group and 23.4% above 60 years; 17.02% patients had a good socioeconomic status (score >60) and 61.70% had poorer socioeconomic status (score <50). Quality of life score (VR-QoL) was ≥50 in 82.9% patients and ≥70 in 14.89%. No significant association existed between VR-QoL scores and demographic factors. However, statistically significant association existed between VR-QoL and age of patient (P < 0.05), postoperative vision (P ≤ 0.05), and contrast sensitivity (P ≤ 0.01).Conclusion:Bilateral lamellar corneal grafts provide satisfactory visual outcomes compatible with day-to-day functioning. VR-QoL has a direct correlation to the age, visual acuity, contrast sensitivity, and inverse correlation with lenticule thickness in DSAEK and residual bed thickness in DALK.     

Clinical results of triple Descemet's stripping and automated endothelial keratoplasty (DSAEK)

PurposeTo evaluate visual acuity (VA), refractive outcome, endothelial cell loss rate and complications of Descemet's stripping and automated endothelial keratoplasty (DSAEK) combined with phacoemulsification and intraocular lens (IOL) implantation in patients with coexisting corneal endothelial dysfunction and cataracts.MethodsSeventeen patients underwent phacoemulsification and posterior chamber IOL implantationthrough temporal corneal incision, followed by DSAEK. The selection of IOL power was predicted by preoperative lens power calculations of fellow eye plus 0.5 to 1.0 diopters (D).ResultsThere were five cases of laser iridotomy induced corneal dysfunction, four cases of Fuch's dystrophy, three cases of cytomegalovirus (CMV) endotheliitis, three cases of iridocorneal endothelial (ICE) syndrome, one case of herpes simplex virus (HSV) endotheliitis, and one case with an unknown cause. The BSCVAs were all under 0.2 preoperatively, and the average BSCVA was 0.3 postoperatively. The postoperative spherical equivalent (SE) refractive error was ?0.11 D on an average. The endothelial cell loss rate was ?36.86% at 6 months and ?38.60% at 12 months. There was one case of graft rejection at 6 months, and one case of primary graft failure. Complications such as donor detachment, pupillary block, donor graft folds, epithelial ingrowth, or interface scar did not occur.ConclusionThis case series of DSAEK combined with phacoemulsification and IOL implantation suggests that the procedure provides rapid visual rehabilitation and allows the selection of an appropriate IOL.     

Comparison of penetrating and endothelial keratoplasty in patients with iridocorneal endothelial syndrome: A registry study

Background

To compare graft survival of endothelial keratoplasty (EK) versus penetrating keratoplasty (PK) in patients with iridocorneal endothelial (ICE) syndrome and identify ocular features associated with graft survival.

Methods

Observational, prospective, cohort study. A total of 30 806 first grafts performed between 1985 and 2020 were identified through the Australian Corneal Graft Registry and included in this observational, prospective cohort study. A total of 196 eyes underwent a primary corneal graft for ICE syndrome. Kaplan–Meier graft survival plots and Chi-squared tests were performed to identify graft survival rates for EK and PK. A history of raised intraocular pressure (IOP) was also recorded and analysed. Graft survival of eyes with ICE syndrome were compared to that of other indications.

Results

Grafts performed for ICE syndrome increased to 0.8% of all cases during the 2005 to 2020 period compared with 0.5% between 1985 to 2004 (χ²=9.35, p = 0.002). From 2010, EK surpassed PK as the preferred graft type. Survival of primary grafts in eyes with ICE syndrome was lower than for other indications (log-rank = 56.62, p < 0.001). Graft survival was higher following PK than Descemet stripping (automated) endothelial keratoplasty (DS(A)EK) (log-rank = 10.56, p = 0.001). Graft survival was higher in eyes without a history of raised IOP compared to those with a reported history of raised IOP (log-rank = 13.06, p < 0.001).

Conclusions

ICE syndrome carries a poor prognosis for graft survival. DS(A)EK had a poorer prognosis than PK. A history of raised IOP is associated with higher risk of graft failure.     

Identifying causes for poor visual outcome after DSEK/DSAEK following secondary DMEK in the same eye

Purpose: To identify causes of reduced visual acuity after Descemet stripping (automated) endothelial keratoplasty (DSEK/DSAEK) and to determine whether such eyes can be successfully ‘repaired’ with a secondary Descemet membrane endothelial keratoplasty (DMEK). Methods: Twelve eyes of 12 patients, who underwent secondary DMEK to manage poor visual outcome after initial DSEK/DSAEK, were evaluated with biomicroscopy, Pentacam imaging, and specular and confocal microscopy, before and at 1, 3 and 6 months after DMEK. Results: Four causes of reduced optical quality of the transplanted host cornea could be identified in DSEK/DSAEK: five eyes (42%) showed large host‐Descemet remnants within the visual axis during surgery; six eyes (50%) irregular graft thickness; six eyes subtle ‘stromal waves’; and nine eyes (75%) high reflectivity at the donor‐to‐host interface. After DMEK graft replacement, all corneas cleared and achieved a best corrected visual acuity of ≥20/25 (≥0.8), except for one with a partial Descemet graft detachment. Pachymetry values decreased from 670 (±112) μm before to 517 (±57) μm after secondary DMEK. Higher‐order aberrations (Coma and Trefoil) at the posterior surface tended to be lower (p = 0.07) in DMEK grafts than in DSEK/DSAEK grafts. Conclusion: Host‐Descemet remnants at the donor‐to‐host interface, interface reflectivity, graft thickness irregularity and donor stromal contraction may contribute to poor visual outcome after DSEK/DSAEK, without causing permanent host corneal damage, as in most cases, complete visual recovery could be achieved by performing a secondary DMEK.     

Visual acuity and endothelial cell density with respect to the graft thickness in Descemet's stripping automated endothelial keratoplasty:one year results

AIM: To evaluate the visual acuity and endothelial cell density according to thethickness in Descemet's stripping automated endothelial keratoplasty (DSAEK) one year after surgery.METHODS: DSAEK patients' data were reviewed. Thirty-seven eyes of 37 patients who underwent DSAEK for pseudophakic bullous keratopathy (PBK) were included in this study. Graft thickness was measured with optical coherence tomography (OCT) 12mo after DSAEK. Eyes were divided into 3 groups based on the graft thickness:thick (>200 μm), medium-thick (150-200 μm) and thin (<150 μm). Best corrected visual acuity (BCVA), endothelial cells density (ECD) and complications were assessed and comparisons were done between groups.RESULTS:There was no significant difference in age, sex, preoperative BCVA, or follow-up period between DSAEK groups. At postoperative 12mo, mean BCVA was 0.28±0.10 in thick graft group, 0.52±0.08 in medium-thick graft group, and 0.72±0.06 in thin graft group. Thin grafts showed better postoperative BCVA as compared with the medium-thick and thick grafts (P=0.001). Thick graft group had 1637.44±88.19-mm², medium thick graft had 1764.50±34.28-mm² and thin graft group had 1845.30±65.62-mm² ECD at 12mo after the surgery. Thin graft group had better ECD at 12mo after surgery (P=0.001).CONCLUSION: Thin grafts after DSAEK ensure better visual rehabilitation. Eyes with thin grafts had significantly lesser loss of ECD compared to eyes with medium-thick and thick grafts one year after surgery.     

The relationship between corneal subbasal nerve density and corneal sensitivity in patients with Fuchs endothelial corneal dystrophy

Purpose:The aim of this study was to investigate the association between alterations in corneal subbasal nerve plexus and tactile corneal sensitivity in patients with Fuchs’ endothelial corneal dystrophy (FECD).Methods:This retrospective, cross-sectional study included 24 (10 M/14 F) patients with FECD and 25 age- and sex-matched (10 M/15 F) healthy subjects as controls. Subjects with FECD were classified as having early (grades 1 and 2) and late (grades 3 and 4) disease. All subjects underwent central corneal tactile sensitivity measurements with the Cochet–Bonnet esthesiometer (Luneau Ophthalmologie, Chartres, France) and subbasal nerve density evaluation using in vivo confocal microscopy (IVCM). Association between corneal nerve plexus density and corneal sensitivity alterations were evaluated using the Mann–Whitney U test and the Spearman correlation test.Results:Compared to healthy subjects (mean age = 60.4 ± 7.5 years), patients with FECD (mean age = 60.6 ± 8.0 years) had worse central corneal sensitivity scores (5.9 ± 0.1 cm vs. 4.2 ± 0.8 cm; P < 0.001), reduced corneal nerve fibers (3.4 ± 1.3 nerves/frame vs. 5.0 ± 0.9 nerves/frame; P < 0.001) and lower corneal subbasal nerve plexus densities (2229.4 ± 364.3 μm/mm² vs. 1901.6 ± 486.8 μm/mm²; P = 0.050). Patients with late stage FECD demonstrated lower subbasal nerve densities as compared to those with early disease (2204.3 ± 313.1 μm/mm² (range = 1523–2552 μm/mm²); 1397.1 ± 227.4 μm/mm² (range = 1120-1834 μm/mm²); P < 0.001). In the FECD group, subbasal nerve density was found to be directly correlated with corneal sensitivity scores (r = 0.457, P = 0.025).Conclusion:Progressive loss of the corneal subbasal nerve plexus appears to be a consistent feature of FECD. Reduction of the corneal nerve plexus parallels the decrease in corneal sensitivity in this patient population.     

The Intraoperative Corneal Pachymetry Changes during Accelerated Corneal Cross-linking in Progressive Keratoconus Patients with Thin Corneas

PurposeTo report the intraoperative corneal pachymetry changes during accelerated corneal cross-linking (A-CXL) in progressive keratoconus patients with thin corneas.MethodsThirty-six eyes (mean age, 22.26 ± 4.02 years) with progressive keratoconic thin corneas (<400 μm without epithelium) who underwent A-CXL with ultraviolet (UV)-A (UVA) (9 mW/cm²) using isotonic riboflavin5-phosphate 0.1% with 1.1% hydroxypropyl methycellulose (RF-HPMC, MedioCROSS M) were included in this retrospective study. Intraoperative corneal pachymetric changes were noted before the procedure, after removal of epithelium, after RF-HPMC instillation, before and after UV irradiation. The mean of corneal pachymetric values were compared statistically.ResultsThe mean corneal pachymetry reduced from 415.72 ± 29.66 to 369.50 ± 23.45 μm after removal of the epithelium (p < 0.05). After the application of RF-HPMC solution the mean thinnest corneal pachymetry (TCP) increased to 412.89 ± 26.94 μm. Statistically significant increase was observed in TCP after saturation with RF-HPMC (p = 0.001). The mean corneal pachymetry before and after UVA irradiation was 419.86 ± 10.41 and 417.47 ± 8.25 μm, respectively (p > 0.05).ConclusionsIsotonic RF-HPMC lead to a significant increase in intraoperative mean TCP. RF-HPMC seems to be a favorable riboflavin option in keratoconus patients with thin corneas.     

Comparison of Each Retinal Layer Thicknesses between Eyes with Central Retinal Vein Occlusion and Normal Contralateral Eyes

PurposeTo evaluate the difference in each retinal layer thickness in central retinal vein occlusion (CRVO) with resolved macular edema after intravitreal antivascular endothelial growth factor injection and normal contralateral eyes..MethodsPatients with ischemic and nonischemic CRVO whose macular edema resolved after intravitreal antivascular endothelial growth factor injections and did not recur for at least 6 months, and a normal contralateral eye were enrolled. Each retinal layer thickness between CRVO and normal contralateral eyes was compared according to Early Treatment Diabetic Retinopathy Study subfields using spectral domain optical coherence tomography.ResultsThe thicknesses of outer nuclear layer, photoreceptor layer, and retinal pigment epithelium in central ring, ganglion cell layer, inner plexiform layer, outer nuclear layer, and photoreceptor layer in the inner ring, and ganglion cell layer in the outer ring of CRVO eyes were significantly thinner than those of normal contralateral eyes (all p < 0.05). Whereas, inner nuclear layer and outer plexiform layer thicknesses in central ring of CRVO eyes were 23.86 ± 8.8 and 25.76 ± 7.6 μm, respectively, which was significantly thicker than those of normal contralateral eyes (19.52 ± 7.7 and 22.76 ± 6.5 μm; p = 0.019 and p = 0.043, respectively). Additionally, the mean best-corrected visual acuity of CRVO eyes were significantly correlated with photoreceptor layer thickness in central ring (p = 0.005).ConclusionsIn CRVO eyes with resolved macular edema, the outer retinal layers were thinner as well as inner retinal layers, whereas inner plexiform layer and outer nuclear layer were thicker than normal fellow eyes. Additionally, photoreceptor layer thickness in foveal area had a significant impact on visual acuity in CRVO.     

Two-year clinical outcome after Descemet membrane endothelial keratoplasty using a standardized protocol

Purpose:The purpose of this study is to evaluate 2-year clinical outcome after Descemet membrane endothelial keratoplasty (DMEK) in a variety of endothelial dysfunctions using a standardized protocol.Methods:From a group of 230 eyes which underwent DMEK for Fuchs'' endothelial corneal dystrophy (FECD), aphakic and pseudophakic bullous keratopathy, failed full thickness corneal transplants, ICE syndrome, failed DSEK, and TASS the clinical outcomes [best spectacle-corrected visual acuity (BSCVA), central endothelial cell density (ECD)] were evaluated before, and at 6, 12, and 24 months and the success rate, failure rate and postoperative complications were also analyzed.Results:Out of 230 eyes, 144 eyes (70%) had BSCVA 6/9 or better 2 years postoperatively. Mean donor ECD was 2692.23 (range, 2300–3436) cells/mm² preoperatively, which was reduced to 1433.64 (range, 619.0–2272.0) cells/mm² 2 years after DMEK surgery, indicating a mean reduction of 1258 cells/mm² (46%) in ECD.Conclusion:DMEK is a highly successful surgical procedure when following a standard protocol for treating diseases of the corneal endothelium providing a near perfect anatomic restoration and a high degree of visual rehabilitation.     

Descemet’s Membrane Endothelial Keratoplasty with Split Corneal Grafts: The Influence of Tamponade Material and Endothelial Storage Time

Purpose: The aim of this study was to describe the clinical outcome of Descemet’s membrane endothelial keratoplasty (DMEK) performed with split corneal grafts and to evaluate the influence of tamponade material and endothelial storage time on DMEK success.

Material and Method: The records of 43 patients who underwent DMEK surgery with a split corneal graft were reviewed. Diagnosis of the patients, preoperative and postoperative best-corrected visual acuity (BCVA), corneal and endothelial storage time, tamponade material, complications, and success rates were specifically tabulated.

Results: The most common indication for DMEK was pseudophakic bullous keratopathy (n = 25, 58.2%). Re-bubbling was needed in 10 cases (23.2%), and a re-DMEK was scheduled in 2 cases and penetrating keratoplasty in 4 cases (9.3%). BCVA improved significantly postoperatively (p < .001). There was an insignificant trend towards a lower re-bubbling rate and better long-term anatomic outcome in favor of 20% SF6 group compared to air tamponade (p = .18 and p = .25). There was no significant difference between the early endothelial transplant (<24 h) and delayed endothelial transplant (3 to 14 days) groups for anatomic success, corneal thickness or BCVA (p = .94, p = .13 and p = .35).

Conclusion: The success rate of DMEK was satisfactory with split corneal grafts. There was no adverse influence of delayed endothelial transplantation on clinical outcome. The success rate of 20% SF6 tamponade was slightly better than room air.     

Mushroom keratoplasty in pediatric patients

Objective

To report the outcome of mushroom keratoplasty for the treatment of full thickness corneal disease in pediatric patients with healthy endothelium.

Methods

A retrospective analysis of pediatric patients who underwent mushroom keratoplasty. The medical records of pediatric patients suffering from full thickness corneal stromal disease with normal endothelium who underwent mushroom keratoplasty at our Institution were included. A two-piece donor graft consisting of a large anterior stromal lamella (9.0 mm in diameter and ±250 μm in thickness) and a small posterior lamella (5–6.5 mm in diameter) including deep stroma and endothelium, prepared with the aid of a microkeratome had been transplanted in all cases. Ophthalmic examination including slit lamp examination, best corrected visual acuity, and corneal topography was performed preoperatively and at each postoperative visit on all patients. The endothelial cells were assessed by specular microscopy in these patients.

Results

Six eyes of six patients (five males and one female) were included. The mean age was 9.3 years (range 5–15 years). Average follow-up was 17.8 months (range 9–48 months).There were no early or late complications recorded. All corneas were clear at the last follow up visit.Preoperative best corrected visual acuity (BCVA) was worse than 20/70 in all six eyes. Postoperatively, four eyes achieved BCVA of 20/40 or better.Endothelial cell loss (n eyes = 3 averaged 24% (range 19–31%). The mean endothelial cell loss was 24% (range 19–31%) among these patients.

Conclusions

Microkeratome assisted mushroom keratoplasty is a viable surgical option for pediatric eyes with full thickness corneal stromal disease and healthy endothelium. Mushroom keratoplasty combines the refractive advantage of a large penetrating keratoplasty with the survival advantage of a small penetrating keratoplasty. Furthermore, mushroom keratoplasty exhibits the mechanical advantage of a shaped keratoplasty.     

Corneal endothelial cell density and microvascular changes of retina and optic disc in autosomal dominant polycystic kidney disease

Purpose:Vascular endothelial dysfunction in autosomal dominant polycystic kidney disease (ADPKD) may affect the retinal vascular parameters due to structural similarities of kidney and retina. We aimed to evaluate the microvascular changes of retina and optic disc and also corneal endothelial cell density in patients with ADPKD.Methods:Forty-six eyes of 23 patients with ADPKD (Group 1), and 46 eyes of 23 sex- and age-matched healthy controls (Group 2) were included in this cross-sectional study. Demographic and ophthalmic findings of participants were collected. Corneal endothelial cell density (CECD) measurements were obtained by noncontact specular microscopy. Foveal retinal thickness, peripapillary retinal nerve fiber layer (RNFL) thickness, vessel density in different sections of the retina and optic nerve head were analyzed by optical coherence tomography angiography.Results:The mean ages were 41 ± 11 years for Group 1 and 39 ± 10 years for Group 2 (P = 0.313). CECD values were significantly lower in group 1 when compared to group 2 (2653 ± 306 cells/mm² and 2864 ± 244 cells/mm², respectively, P < 0.001). The foveal retinal thickness and RNFL thickness were similar, but superior quadrant thickness of RNFL was significantly lower in Group 1 than Group 2 (126 ± 14 μm vs. 135 ± 15 μm, P = 0.003). In Group 1, whole image of optic disc radial peripapillary capillary densities were significantly lower compared to Group 2 (49.4 ± 2.04%, and 50.0 ± 2.2%, respectively, P = 0.043). There was no significant difference regarding superficial, deep retinal vessel densities, foveal avascular zone and flow areas between the groups (P > 0.05 for all).Conclusion:Lower CECD values and decreased superior quadrant RNFL thickness, and microvascular densities of optic disc were revealed in patients with ADPKD. Evaluation of CECD and retinal microvasculature may be helpful in the management of these patients.     

Suture pull-through insertion of graft donor in Descemet stripping automated endothelial keratoplasty: Results of 4-year follow-up

Purpose:

To report our clinical experience and 4-year follow-up results of Descemet stripping automated endothelial keratoplasty (DSAEK) with the suture pull-through insertion technique.

Methods:

This is a retrospective study of 195 eyes in which a posterior lamellar keratoplasty was performed between 2007 and 2011. The insertion of a folded donor lenticule was performed with a double-armed 10-0 suture using a straight transchamber needle and half-circle needle. Endothelial cell density was measured annually up to 4 years after the surgery, and cell loss was calculated based on the median preoperative donor endothelial cell density. Postoperative complications, primary graft failure, pupillary block, and dislocation of the donor tissue were assessed.

Results:

All patients underwent uncomplicated DSAEK. Data were available for 195 eyes (100%) at 1 year, 186 eyes (95.3%) at 2 years, 176 eyes (90.2%) at 3 years, and 160 eyes (82%) at 4 years. Median preop-erative donor endothelial cell density was 2688 cells/mm² [interquartile range (IQR) 207.5 cells/mm²], which decreased by 27% at 1 year (1956 cells/mm², IQR 264.8 cells/mm²), 31% at 2 years (1855 cells/mm², IQR 320.5 cells/mm²), 35% at 3 years (1756.5 cells/mm², IQR 306.5 cells/mm²), and 36% at 4 years (1709.5 cells/mm², IQR 288,0 cells/mm²). Nine patients (4.6%) had a dislocation of donor tissue; all were successfully reattached with a second air injection. Only three eyes (1.5%) developed graft failure. Pupillary block was present in 15 eyes (7.7%).

Conclusion:

DSAEK with suture pull-through insertion of donor graft represents a simplified and safe technique that has endothelial cell loss comparable with other techniques and low rates of intraoperative and postoperative complications.     

不同病因对角膜内皮移植术后视力的影响

背景 角膜后弹力层剥除联合自动角膜刀取材内皮移植术（DSAEK）是目前治疗角膜内皮失代偿的首选术式,但不同角膜病变患者术后视力恢复情况国内外的报道有所不同. 目的 比较不同病因所致角膜内皮失代偿患者DSAEK术后视功能的恢复情况,评价不同角膜病变对DSAEK术后视力的影响. 方法 回顾性分析2007年12月至2009年12月在北京大学第三医院眼科就诊的角膜内皮失代偿患者67例71眼的临床资料,根据原发病因的不同将其分为Fuchs角膜内皮营养不良组19例22眼、白内障术后大泡性角膜病变组36例37眼及其他因素引起的角膜内皮失代偿者（其他病因组）12例12眼,所有患眼均行DSAEK,分析其术后第1、3、7、30、90、180天各组术眼视力改善情况,采用SPSS 16.0统计学软件的x2检验和重复测量两因素方差分析对各组术眼手术前后不同视力的眼数分布及不同病因组在不同时间点LogMAR视力的差异进行比较. 结果 入选的71眼中,71.83％的患眼术前视力低于0.1,所有患眼视力均低于0.3.术前Fuchs角膜内皮营养不良组、白内障术后大泡性角膜病变组和其他病因组总体比较视力差异无统计学意义（x2=3.427,P＞0.05）.术后第1 80天,Fuchs角膜内皮营养不良组视力≥0.8者5眼,占22.73％,略高于白内障术后大泡性角膜病变组的10.81％和其他病因组的8.33％,但3个组间不同视力的眼数分布差异无统计学意义（x2=0.330,P＞0.05）.3个组患眼随着术后时间的延长,LogMAR视力值逐渐下降,差异有统计学意义（F时间=88.000,P＜0.01）;术后第7天,白内障术后大泡性角膜病变组LogMAR视力值为1.29±177;0.57,明显高于Fuchs角膜内皮营养不良组的0.82±177;0.43和其他病因组的0.91±177;0.39,差异均有统计学意义（P＜0.05）;术后第90天,Fuchs角膜内皮营养不良组LogMAR视力值为0.40±177;0.28,明显低于白内障术后大泡性角膜病变组的0.64±177;0.44和其他病因组的0.73±177;0.54,差异均有统计学意义（P＜0.05）;而术后第180天,3个组间LogMAR视力值的差异均无统计学意义（P＞0.05）.Fuchs角膜内皮营养不良组视力在术后3个月时达稳定,白内障术后大泡性角膜病变组和其他病因组术后90～ 180 d视力仍有变化. 结论 DSAEK是治疗各种角膜内皮失代偿的有效方法,Fuchs角膜内皮营养不良、白内障术后大泡性角膜病变和其他病因引起的角膜病变行DSAEK术后6个月视力均恢复较好,但Fuchs角膜内皮营养不良患者术后视力恢复更快.     

Study of change in contrast sensitivity in relation to depth of ablation after wavefront optimized myopic laser-assisted in situ keratomileusis

Purpose:The aim of this work was to study the change in contrast sensitivity (CS) in relation to depth of stromal ablation after wavefront-optimized (WFO) myopic laser in situ keratomileusis (LASIK).Methods:This was as prospective, longitudinal, comparative study. The study participants were divided into two groups: Group 1 ≤50 μ ablation depth; 60 eyes and group 2 >50 μ ablation depth; 60 eyes. All underwent WFO LASIK. Uncorrected and corrected distance visual acuity (UDVA and CDVA) and CS were measured preoperatively and postoperatively at 1 week, 2 weeks, and 2 and 6 months. Two-way repeated-measures analysis of variance (ANOVA), Unpaired t test and one-way repeated measures ANOVA were used to test differences across time periods within each treatment group. A value of P < 0.05 was considered as statistically significant.Results:The mean ablation depths in groups 1 and 2 were 39.30 μ ± 7.22 μ and 69.90 μ ± 12.09 μ, respectively; the maximum depth was 94.62 μ. In group 1, the preoperative mean CS was 1.91 ± 0.07, which improved postoperatively at 1 week (1.93 ± 0.06) and remained stable in subsequent follow-ups (1.94 ± 0.05). In group 2, the mean CS preoperatively was 1.87 ± 0.12, which postoperatively at 1 week and 6 months were 1.93 ± 0.07 and 1.94 ± 0.03, respectively (P < 0.05). Between the groups, preoperative CS was significantly different (P = 0.04), but the change in CS post-LASIK was insignificant (P > 0.05).Conclusion:There was a significant improvement in CS after WFO myopic LASIK in all patients irrespective of ablation depth (up to 94.62 μ).     

Management of Acute Submacular Hemorrhage with Intravitreal Injection of Tenecteplase,Anti-vascular Endothelial Growth Factor and Gas

PurposeTo evaluate the visual and anatomical outcomes for neovascular age-related macular degeneration with submacular hemorrhage after intravitreal injections of tenecteplase (TNK), anti-vascular endothelial growth factor (VEGF) and expansile gas.MethodsThis study was a retrospective clinical case series following 25 eyes of 25 patients. All patients received a triple injection using 0.05 mL TNK (50 µg), 0.05 mL anti-VEGF and 0.3 mL of perfluoropropane gas. Retreatment with anti-VEGF was performed as needed. Preoperative and postoperative best-corrected visual acuity and central retinal thickness were analyzed.ResultsThe mean logarithm of the minimum angle of resolution of best-corrected visual acuity improved significantly from 1.09 ± 0.77 at baseline to 0.52 ± 0.60 at 12 months (p < 0.001). The mean central retinal thickness also improved significantly from 545 ± 156 at baseline to 266 ± 107 at 12 months (p < 0.001). A visual improvement of 0.3 logarithm of the minimum angle of resolution unit or more was achieved in 15 eyes (60%). During the 12 postoperative months, an average of 4.04 intravitreal anti-VEGF injections was applied.ConclusionsA triple injection of TNK, anti-VEGF, and a gas appears to be safe and effective for the treatment of submacular hemorrhage secondary to neovascular age-related macular degeneration.     

The role of postoperative positioning after DSAEK in preventing graft dislocation

Purpose: The aim of the study was to evaluate the importance of immediate postoperative supine patient positioning after Descemet stripping automated endothelial keratoplasty (DSAEK). Methods: Forty eyes from 40 patients who underwent DSAEK were randomized into two groups: 20 patients sat in a chair for 2 hr postoperatively (group 1), and 20 patients were placed in a supine position (group 2) for the same time interval. At the end of surgery, the anterior chamber was fully filled with air, aiming at an intraocular pressure (IOP) of approximately 20 mmHg. The dislocation rate in the two groups was registered. IOP was measured 2 hr postoperatively and compared with endothelial cell loss at 6 months. Results: There was no statistically significant difference in the dislocation rate between the two groups (p = 0.548): two patients (10%) in group 1 and one patient (5%) in group 2. Endothelial cell loss at 6 months was 29.6% and 29.7% in group 1 and 2, respectively. There was no correlation between the IOP 2 hr after surgery and endothelial cell loss at 6 months (p = 0.741). Conclusion: Supine positioning does not seem to be of crucial importance in avoiding graft dislocation in DSAEK when the anterior chamber is fully filled with air for 2 hr postoperatively.     

Effects of a Novel Push-through Technique Using the Implantable Collamer Lens Injector System for Graft Delivery during Endothelial Keratoplasty

Purpose

To investigate effects of a new push-through insertion method for donor lenticules using an injector system on endothelial viability ex vivo and in a clinical case series of endothelial keratoplasty.

Methods

An ex vivo delivery model was used with porcine corneoscleral rims. We compared the endothelial viability in a new push-through insertion method using the Visian Implantable Collamer Lens (ICL) injector versus that of standard forceps-assisted insertion for lenticule delivery. Twenty porcine corneal lenticules were divided into four groups by insertion method and wound size. Vital dye staining was performed and devitalized areas were semi-quantitatively assessed by digital imaging. In the clinical case series, Descemet''s stripping endothelial keratoplasty (DSEK) using the push-through method was performed in seven patients and endothelial outcome was determined six months postoperatively.

Results

Mean devitalized areas for the push-through method were significantly lower than for forceps-assisted insertion through 3.2 mm incision (23.99 ± 2.17% vs. 50.48 ± 5.07%, p = 0.009) in the ex vivo model. Average endothelial cell counts of donor tissues of patients who underwent DSEK were 26.4% lower six months postoperatively.

Conclusions

Push-through delivery of donor lenticules using the Visian ICL injector system appears to be less harmful to endothelial cells than conventional forceps-assisted delivery.     

Intravitreal Anti-vascular Endothelial Growth Factor for Newly Diagnosed Symptomatic Polypoidal Choroidal Vasculopathy with Extrafoveal Polyps

PurposeTo evaluate the 12-month outcome of anti-vascular endothelial growth factor (VEGF) treatment for extrafoveal polypoidal choroidal vasculopathy (PCV).MethodsThis retrospective observational study included 32 eyes of 32 patients newly diagnosed with extrafoveal PCV (polyps located more than 500 µm from the center of the fovea). Patients were treated with intravitreal ranibizumab, bevacizumab, or both. The best-corrected visual acuity (BCVA) and central foveal thickness (CFT) at diagnosis and at 12 months were compared. Eyes were divided into two groups according to the presence of submacular hemorrhage. The BCVA in each group was compared at baseline and at 12 months.ResultsDuring the 12-month study period, patients received an average of 4.0 ± 1.1 anti-VEGF injections. The BCVA at baseline, three-month post-diagnosis, and 12-month post-diagnosis was 0.59 ± 0.40, 0.34 ± 0.38, and 0.38 ± 0.38, respectively. The BCVA at 12 months was significantly better than the baseline value (p = 0.002). The CFT at baseline, three-month, and 12-month post-diagnosis was 477.1 ± 194.2 µm, 214.5 ± 108.8 µm, and 229.8 ± 106.1 µm, respectively. The CFT at 12 months was significantly lower than the baseline value (p < 0.001). A significant improvement in BCVA was noted in eyes with and without submacular hemorrhage (n = 13, p = 0.032 and n = 19, p = 0.007, respectively).ConclusionsAnti-VEGF therapy was beneficial in extrafoveal PCV, regardless of the presence of submacular hemorrhage.     

Descemet-stripping automated endothelial keratoplasty: a successful alternative to repeat penetrating keratoplasty

Background: Although Descemet‐stripping automated endothelial keratoplasty has replaced penetrating keratoplasty for primary treatment of endothelial disorders, many patients have already undergone penetrating keratoplasty. It is unclear when repeat penetrating keratoplasty is necessary or when endothelial keratoplasty may restore clarity to a failed graft. Design: Retrospective case series of patients undergoing Descemet‐stripping automated endothelial keratoplasty after penetrating keratoplasty by three surgeons at an academic tertiary care centre. Participants: Eight patients with Descemet‐stripping automated endothelial keratoplasty after penetrating keratoplasty from 2006 to 2009. Methods: Microkeratome‐prepared Descemet‐stripping automated endothelial keratoplasty donor tissue was used. In seven cases, the penetrating keratoplasty bed was neither stripped nor scraped, and in one, scraping only was performed. Main Outcome Measures: Preoperative and 6‐month postoperative best‐corrected visual acuities in logMAR (logarithm of the minimum angle of resolution). Results: The average pre‐Descemet‐stripping automated endothelial keratoplasty best‐corrected visual acuity was 1.375, and the average best‐corrected visual acuity 6 months postoperatively was logMAR 1.0, a 2.5‐fold improvement in the minimum angle of resolution (P = 0.22). Seven of the eight patients showed an improvement in best‐corrected visual acuity, and one patient had failure of Descemet‐stripping automated endothelial keratoplasty and required penetrating keratoplasty. Five had a postoperative event: one had a gap that resolved spontaneously, three required rebubblings (injections of air only without otherwise repositioning the graft), and one experienced graft failure. Conclusions: Descemet‐stripping automated endothelial keratoplasty can successfully rescue a prior penetrating keratoplasty, even with a fairly high detachment rate. Given these favourable visual outcomes, further study of this promising strategy is justified.