Results of Therapeutic Penetrating Keratoplasty

Purpose By a retrospective study of patients in the Ankara Hospital Eye Clinic, to determine the anatomical and visual results of therapeutic penetrating keratoplasty (PK) and its role in the management of corneal disease.Methods Therapeutic PK was performed in 36 patients (37 eyes) who had corneal perforation due to corneal disease (23 eyes) or eyes in which perforation was imminent (14 eyes). Initial indications for grafting were nonperforated descemetocele without inflammation (six eyes, 16.2%); nonperforated bacterial corneal ulcer (five eyes, 13.5%); nonperforated herpetic keratitis with active stromal inflammation (two eyes, 5.4%); acanthamoeba keratitis (one eye, 2.7%); perforation due to herpetic keratitis (13 eyes, 35.2%); perforation due to persistent epithelial defect (8 eyes, 21.6%); or perforation due to bacterial corneal ulcer (two eyes; 5.4%). The results were evaluated for each of the following criteria: anatomical integrity of the eye, cure of the disease, complications, graft clarity, and visual acuity.Results Anatomical integrity was achieved in 21 of the 23 eyes (91.3%) perforated from corneal disease. Therapeutic PK cured the disease in all bacterial keratitis cases. The proportion of clear grafts was 60.9% in the 23 eyes perforated from corneal disease, and 57.1% in the 14 eyes in which perforation was imminent. Fifteen eyes (40.5%) obtained a final visual acuity of 20/100 or better; five of these eyes were not yet perforated before the PK.Conclusions Therapeutic PK is effective in the management of the eye with active uncontrolled infection or perforation from corneal disease. Approximately half of our patients maintained a clear graft at the last visit. Without therapeutic surgery, these eyes would have been lost. Jpn J Ophthalmol 2004;48:368–371 © Japanese Ophthalmological Society 2004     

中浅层真菌性角膜炎治疗方式选择分析

目的 分析研究药物保守治疗、羊膜移植和板层角膜移植(lamellar keratoplasty,LKP)在中浅层真菌性角膜炎治疗中效果.方法 对2008年1月至2009年12月就诊的中浅层真菌性角膜炎病人应用裂隙灯观察感染累及角膜组织的中浅层,未累及角膜全层的35例患者.角膜刮片或角膜病理切片,两者中有一项查见菌丝者确诊为真菌性角膜炎.给予全身局部抗真菌治疗.局部2～3 d角膜溃疡清创一次,碘酊烧灼5 s钟后生理盐水冲洗.病情迁延不愈的患者,在局麻下行角膜清创,如病灶累及角膜厚度1/3以内,行羊膜移植术;如感染灶累及角膜厚度1/3以上且未累及角膜全层,行LKP术.结果 9例患者通过药物保守治疗后治愈.17例患者行角膜清创联合羊膜移植术治疗,其中16例治愈,1例复发后行LKP术治愈.10例患者行LKP术治愈(包括羊膜移植术后复发的1例患者).结论 药物治疗可以有效治愈部分中浅层真菌性角膜炎,对于药物保守治疗持续不愈的患者可以选择羊膜移植和LKP术治疗.     

羊膜移植联合羊膜覆盖治疗真菌性角膜炎分析

目的 探讨角膜清创联合羊膜移植羊膜覆盖治疗真菌性角膜炎的手术适应证的选择和临床效果.方法 2008年3月至2009年11月就诊的17例真菌性角膜炎患者,视力为FC/50cm～0.2,经角膜刮片法10%KOH溶液处理后查见菌丝,常规全身、局部抗真菌治疗3周至2个月后,患者病情迁延不愈,角膜涂片仍见菌丝.手术适应证为感染深度小于1/3角膜厚度,感染范围小于1/3角膜面积.手术方式:在局麻下行角膜清创,至角膜植床无明显感染迹象.溃疡面行羊膜小植片移植,角膜表面行羊膜大植片覆盖.术后结膜下注射0.2%氟康唑注射液0.5ml.结果 16例患者术后视力为0.5～1.0,感染得到控制.羊膜小植片与角膜融合,可见角膜组织内云翳形成.1例患者术后感染灶融解,改行板层角膜移植术后治愈.结论 角膜清创联合羊膜移植羊膜覆盖可以有效治疗药物难以治愈的表浅真菌性角膜炎.良好的手术适应证的选择不仅可以治愈真菌性角膜炎,而且可以获得良好的术后视力.真菌复发和角膜融解是手术后的危险因素.     

Peripheral ulcerative keratitis: Our challenging experience

A 52 year old male presented with peripheral ulcerative keratitis in the right eye. Patient’s history included retinitis pigmentosa, pseudophakia (right eye), cataract (left eye), bilateral partial deafness, ischemic heart disease, hypertension, type 1 diabetes mellitus, depression, hyperparathyroidism, hypertriglycemia and renal failure. The patient was on weekly hemodialysis. The peripheral corneal ulceration remained stable until he developed sudden and rapid thinning after eight months of regular follow up and management.Laboratory investigations including immunological studies were negative and we had to rely on treatment based on clinical signs, including the visual acuity, size, depth and staining of the ulcer and perilimbal, episcleral, scleral, corneal and anterior chamber reactions. The patient was treated with medical and conservative approaches and the eye was protected with a plastic shield to avoid injury. Despite our efforts, the patient perforated his eye due to a trivial trauma during sleep. He was managed successfully with cyanoacrylate glue and a bandage contact lens. The anterior chamber reformed after the perforation was sealed and the patient is on a regular follow up with a multidisciplinary approach.     

Excision with Corneoscleral Lamellar Keratoplasty and Amniotic Membrane Transplantation of a Corneal Displaced Recurrent Conjunctival Melanoma

An 81-year-old woman with a raised pigmented nodule over her left cornea for 7 months duration was examined. Dark conjunctival pigmentation was observed in the upper bulbar fornix conjunctiva. She had previously undergone primary surgical excision of a malignant conjunctival melanoma four years earlier. The tumor separated easily from the corneal surface, but remained slightly attached to the corneoscleral surface. A corneoscleral lamellar dissection of 3 mm in width and 2 mm in depth as well as a corneoscleral lamellar keratoplasty for the reconstruction of the corneoscleral defect were performed. The wide upper bulbar and fornix conjunctiva were excised, and an amniotic membrane transplantation was performed. Biopsy revealed an invasive melanoma with a depth of 1 mm. Left, right, and inferior tumor margins of the corneoscleral lesion and the pigmentary lesion in the conjunctiva were free of the tumor. After surgery, 0.04% mitomycin was administered topically 4 times daily for 4 weeks. There was no recurrence 2 years after surgery, and systemic evaluation revealed no metastasis.     

Clinical outcome and course of Tenon’s patch graft in corneal perforation and descemetocele

Purpose:To assess the efficacy and clinical outcome of Tenon’s patch graft (TPG) in corneal perforation and descemetocele.Methods:In this retrospective study, medical records of 83 patients (85 eyes) who underwent TPG for corneal perforation (58, 68%) or descemetocele (27, 32%) between July 2018 and October 2021 were reviewed. Clinical examination and anterior segment optical coherence tomography (AS-OCT) were performed on every follow-up visit. Anatomical success was considered as the restoration of the structural integrity with the formation of scar and anterior chamber (AC).Results:The mean size of the corneal lesions (corneal perforation or descemetocele) was 4.20 ± 1.01 mm. The mean follow-up period was 9.2 ± 5.48 months. The common underlying etiologies were infectious keratitis in 48% and autoimmune disorders in 35% of cases. TPG successfully restored the globe integrity in 74 (87%) eyes (83% in perforation and 96% in descemetocele). Anatomical failure occurred in 11 eyes (13%). The failures were due to graft dehiscence (8 eyes), graft ectasia (1 eye), and scarring with flat AC (2 eyes). The median time to epithelialization and scar formation were 3 and 15 weeks, respectively. Logistic regression analysis showed few predictors for a successful outcome: descemetoceles, noninfective causes, viral keratitis in infectious etiology, and paracentral or peripheral lesions.Conclusion:TPG can be considered an effective and inexpensive treatment for restoring the structural integrity in the eyes with perforations and descemetoceles, particularly when the donor tissue is unavailable. AS-OCT is a valuable noninvasive tool for monitoring the graft status.     

多层羊膜联合结膜瓣覆盖治疗周边溃疡性角膜炎分析

目的 应用多层羊膜移植联合结膜瓣覆盖的手术方法治疗近穿孔的周边溃疡性角膜炎,从而探讨该手术方法的临床价值.方法 自2008-2011年收集的21例(21只眼)周边溃疡性角膜炎近穿孔病例,其周边凹槽样角膜溶解,厚度约1/3～1/4CT,术前血液风湿系列检查所有患者显示异常,其中类风湿因子(RF)均超出正常值3～5倍,部分患者抗链球菌溶血素O定量测定(ASO)或超敏C反应蛋白测定高于正常值,抗环瓜氨酸多肽(ccp)抗体正常.术前药物控制角膜创面合并的混合感染;术中尽可能清除角膜溃疡局部坏死组织及角膜周边部免疫复合物沉积处,将营养液冷冻法保存羊膜组织片,复水后分层贴附于溃疡表面,上皮面向上,缝线间断固定,溃疡较深处再以羊膜条填塞其中,将自体带蒂转位的结膜瓣覆盖于羊膜表面,间断固定.术后结合局部感染情况给予糖皮质激素眼水、眼膏点眼,同时根据内科会诊意见全身使用糖皮质激素治疗相关性自身免疫性疾病.结果 术后10～14 d,18例患者周边溃疡性角膜炎近穿孔区有新生血管长入,术后1～2月角膜创面愈合;仅3例患者术后1.5月角膜创面再次出现部分结膜、角膜缘组织的溶解,即行第二次同术式手术,二次术后2月角膜创面全部愈合.患者随诊中仅1例患者在术后1年时,在距原手术区1个钟点位处出现新的周边溃疡性角膜炎溃疡病灶.结论 周边溃疡性角膜炎是一种与自身免疫相关性眼病.在角膜供体材料匮乏的今天,多层羊膜联合结膜瓣覆盖为治疗周边溃疡性角膜炎近穿孔病例提供了一种有效的手术治疗方式.     

羊膜移植手术治疗真菌性角膜溃疡

目的 探讨羊膜移植手术对真菌性角膜溃疡的治疗效果。方法 对24例(24眼)真菌性角膜溃疡患者在彻底清除角膜病灶后进行羊膜移植。结果 24例真菌性角膜溃疡行羊膜移植均一次成功愈合良好，随访3～24月，平均12月，未见免疫排斥反应。结论 羊膜移植是治疗真菌性角膜溃疡的一种有效方法。     

Clinical and microbial spectrum of fungal keratitis in Singapore: a 5-year retrospective study

Background: The epidemiology of fungal keratitis varies geographically, but commonly occurs in warm, tropical climates. To determine the microbial and clinical characteristics of this disease in Singapore, we conducted a5-year hospital-based retrospective study. Methods: A retrospective reviewo f culture-positive fungal keratitis at the Singapore National Eye Center and Singapore General Hospital, from January 1991 to December 1995. Results: Twenty-nine consecutive cases of culture-positive fungal keratitis were seen over the study period. The mean age of the cases was 41 years and 23 were males. Amongst the varied occupations, 9 were construction workers. The most common cultured organisms were Fusarium sp. (52%) and Aspergillus flavus (17%). More than half had a history of ocular trauma prior to the development of keratitis, while a quarter had antecedent topical corticosteroid therapy. In contrast, only 2 patients were contact-lens wearers. Despite medical therapy, 10 patients eventually required therapeutic penetrating keratoplasties; of these, 6 were caused by Fusarium species. Conclusion: Fusarium is the commonest cultured organism in fungal keratitis in Singapore and is associated with significant ocular morbidity. This revised version was published online in August 2006 with corrections to the Cover Date.     

纤维蛋白胶在翼状胬肉切除联合无缝线羊膜移植术中应用的临床观察

目的 观察与探讨纤维蛋白胶在翼状胬肉切除联合羊膜移植术中应用的方式方法和临床效果.方法 筛选原发性翼状胬肉患者21人(26只眼),行胬肉切除联合羊膜移植术.所有患者随机分为无缝线组及缝线组:无缝线组11人(13只眼),术中将胬肉组织切除后,采用纤维蛋白胶黏合固定羊膜植片;缝线组10人(13只眼),以10-0尼龙缝线间断缝合固定羊膜植片.术后随访6个月,记录手术时间、术后症状和体征.并应用SPSS统计软件对两组结果进行分析.结果 无缝线组手术时间(13.6±3.5)min明显短于缝线组(22.3±5.2)rain(P<0.01).术后2周内(拆线前),无缝线组术眼疼痛、异物感和流泪等局部刺激症状均显著轻于缝线组(P<0.01).两组术后均未发生植片移位并发症.无缝线组术后羊膜植片贴附紧密,均于术后1周内迅速上皮化.缝线组术后有5只眼(38.5%)发生羊膜下积液,羊膜上皮化较无缝线组略迟,于术后8～ 10d完全上皮化.无缝线组羊膜愈合良好,局部无明显瘢痕发生;缝线组均出现不同程度的缝线刺激性瘢痕.术后6个月随访期内两组均未见胬肉复发.结论 在翼状胬肉切除联合羊膜移植术中使用纤维蛋白胶可替代手术缝线,使用方便,并明显缩短手术时间,减轻术后刺激症状,并利于羊膜愈合、减轻局部瘢痕,达到更好的美容目的 .     

Drug reservoir function of voriconazole impregnated human amniotic membrane: An in vitro study

Purpose:Earlier our group has demonstrated the drug reservoir function of the human amniotic membrane (HAM) using stable moxifloxacin and fortified cefazolin ophthalmic formulations and found it as a suitable tool to deliver drugs for an extended duration. The purpose of this study was to evaluate the extended-release kinetics of voriconazole from the impregnated human amniotic membrane (HAM) in vitro.Methods:HAM buttons were incubated with freshly prepared 1% topical ophthalmic formulation of voriconazole for 5 different exposure time to investigate the ideal exposure time for the extended-release of voriconazole from HAM. The drug release kinetics was studied in simulated tear fluid for 5 weeks and the amount of voriconazole released at different intervals was estimated using high-performance liquid chromatography (HPLC) with photodiode array (PDA) detector.Results:There was a marginal increase in drug entrapment efficiency with increased drug exposure time but neither the drug entrapment nor the drug release was found to be statistically significant (P ≥ 0.5). Voriconazole was detectable even at 5 weeks.Conclusion:A sustained release of voriconazole was achieved up to 5 weeks, when voriconazole was incubated with amniotic membrane for all the studied drug soaking times. Thus, voriconazole impregnated amniotic membrane can be considered for the sustained delivery for its in fungal keratitis.     

Amniotic Membrane Graft with Argon Laser Photocoagulation Versus Amniotic Membrane Graft with Tissue Debridement for Treatment of Mycotic Keratitis

Aim: To compare augmented therapy with argon laser and amniotic membrane graft (AMG) versus AMG and tissue debridement for resistant mycotic corneal ulcers. Methods: This study included 40 cases of resistant fungal corneal ulcers in two groups. In one group, argon laser photocoagulation and AMG were done while AMG with tissue debridement was done as adjunctive therapy for the specific antifungal agents. Results: Complete healing with no adverse effects was achieved in argon laser group in duration ranging from 2-3 weeks in all cases. In the AMG group, duration of healing ranged from 3-5 weeks. Visual acuity was improved with one or more line gain in eight cases (40%) in the laser group, while in six cases (30%) only in the AMG group. Conclusions: Augmented therapy with argon laser and AMG is superior to AMG with tissue debridement for treatment of resistant fungal corneal ulcers.     

穿透性角膜移植术治疗坏死性基质角膜炎23例

目的:探讨穿透性角膜移植术(penetratingkeratoplasty,PKP)治疗坏死性基质角膜炎(necrotizingstromalkeratitis)的手术适应证及其临床效果。方法:按照Holland等的HSK新分类法,选择确诊坏死性基质角膜炎患者,予以局部及全身药物治疗。对病情不能控制,药物治疗无效的患者22例(23眼),其中角膜溶解穿孔3眼,用新鲜角膜组织行穿透性角膜移植术,并随访观察术后疗效。结果:随访3mo～3a,22例(23眼)中,术后视力提高者18眼,其中矫正视力达到0.1～0.5者12眼,0.05～0.1者6眼;无改善者5眼。角膜植片透明17眼,半透明2眼,植片混浊4眼,植片透明率为74%。术后3眼植片发生排斥反应,3眼原发病灶复发。2眼术后因排斥反应及原发病灶反复发作,植片完全混浊,行2次角膜移植术。结论:对坏死性基质角膜炎患者,药物保守治疗无效、角膜坏死穿孔或行将穿孔,及时用新鲜角膜组织行穿透性角膜移植术治疗,不仅能控制炎症,缩短病程,而且能保存眼球,恢复部分视力,因此具有重要临床应用价值。     

深板层角膜移植术治疗病毒性角膜炎疗效观察

目的：探讨深板层角膜移植术治疗单疱病毒性角膜炎的临床疗效。

方法：对105例单疱病毒性角膜炎的患者行深板层角膜移植术。术后随访12～36mo,观察角膜移植片的透明度、视力及病毒性角膜炎复发情况。

结果：患者24例剥离角膜基质至接近后弹力层,81例中央区约6mm×6mm区域达到后弹力层。101例植床透明。术后视力均有不同程度的提高,最佳矫正视力>0.5者67例,0.3～0.5者35例,<0.3者3例。观察期内无病毒性角膜炎复发及排斥反应病例。

结论：深板层角膜移植术是治疗病毒性角膜炎的有效方法,对于视力较差发作频繁的病毒性角膜炎病例应早行手术治疗。     

A simplified ex vivo model to learn the correct orientation of Descemet membrane endothelial graft

We describe a simple, endoilluminator-assisted technique, which enables an easy identification of the descemet membrane endothelial keratoplasty graft orientation, as well as provides its good visualization in the anterior chamber, during all the steps of surgery in the wet lab.     

Ocular surface rehabilitation: Application of human amniotic membrane in high-risk penetrating keratoplasties

Background

Human amniotic membrane is a versatile tool for management of ocular surface disorders. This study evaluates the effect of cryopreserved human amniotic membrane (hAM) on one-year survival of penetrating keratoplasties (PKP) in high-risk recipients.

Method

This is a retrospective noncomparative cohort study of 58 consecutive eyes undergoing PKP with concurrent placement of a self-retained cryopreserved hAM (PROKERA®) at a tertiary care center from January 2009 to July 2010.

Results

Mean patient age was 66.7 ± 17.2 years and 30 (54%) were males. 51 eyes were pseudophakic and one aphakic. 27 eyes were glaucomatous; 24 had glaucoma drainage device and 2 had previous endocyclophotocoagulation. 12 patients had PKP for the first time and 46 had repeat PKP (average number of prior PKP = 1.63 ± 1.1, range: 1–5).Risk factors for graft failure included repeat PKP (79.3%), corneal neovascularization (51.7%), preexisting glaucoma (46.6%), and presence of anterior synechiae (37.9%). Both First Transplant and Repeat Transplant groups had similar survival rates until 6 months after transplant (75% vs 74%, odds ratio = 1.06, p = 1.00). At 12 months, First Transplant group showed a better survival rate (67% vs 43%, odds ratio = 2.60, p = 0.20). Eyes with >3 risk factors had a higher graft failure rate (odds ratio = 5.81, p = 0.003).

Conclusion

Survey of the literature suggests that high-risk PKP with concurrent hAM placement demonstrate comparable graft survival. Presence of multiple risk factors is associated with poor survival.     

Demographic pattern, predisposing factors and management of ulcerative keratitis: evaluation of one thousand unilateral cases at a tertiary care centre

PURPOSE: To determine the predisposing factors, special clinical manifestations and the management of presumed microbial ulcerative keratitis. METHODS: A retrospective study was performed in 1000 eyes of 1000 patients with presumed microbial keratitis. Information was recorded on patients' age and gender, risk factors, seasonal presentation, number of days since initiation of ulcer, prior therapy, clinical presentation, microbiological work-up and case management. RESULTS: Fifty per cent of the patients with corneal ulcers were aged between 36 and 65 years and 13.3% were in the paediatric age group (1 month to <16 years). The male : female ratio was almost 1.6:1. Only 11.4% of patients reported to the authors during the first week of initiation of ulcer. Trauma was the cause in 47.6% of eyes, and ocular surface diseases accounted for 16.6%. Forty-two per cent of eyes received topical antibiotics alone (either one or more) prior to hospital visit and 42.2% of eyes were on topical antibiotics and antifungals. Another 8.2% were on topical corticosteroids along with antibiotics and 4.6% were receiving some unidentified drop. Only 3% of the eyes did not receive any therapy prior to visit. Contact lens use as a risk factor could be identified only in 8.2% of eyes. Ulcers were central in location in 48%. Ulcer size 6-9 mm was observed in 51.7% of eyes. Medical therapy alone was effective in 61.0% of eyes and another 9.7% eyes responded to paramedian tarsorrhaphy along with topical antimicroboial drugs. CONCLUSION: Corneal ulcers are a frequent problem in this part of the world. The ulcers seen at this tertiary referral hospital present late in the natural history of the disease and are clinically severe. Despite the severity a majority of the eyes could be saved anatomically, but almost 65% of eyes were left with a visual acuity of <6/120. Considering the high magnitude of visual loss, public education about the potential for loss of sight and the importance of timely and appropriate treatment is recommended.     

Fibrin glue assisted amniotic membrane graft reconstruction of conjunctival fornix and canthus following excision of conjunctival tumours

Conjunctival tumors involving non-limbal locations, such as the fornix and canthus, are typically excised using a “non-touch” technique, often with a wide surgical margin. Reconstruction of these large defects can be difficult due to the contour of the ocular surface and are often complicated by shortening of the fornix, symblepharon formation, and restriction of eye movements. In our experience, the use of amniotic membrane grafts combined with the sealant properties of fibrin glue such as Tisseel® has improved our surgical outcomes during the reconstruction phase. We would like to highlight and describe our surgical technique using fibrin glue and squint hooks to aid amniotic membrane graft reconstruction for surgically challenging locations in the fornix and canthus following excision of conjunctival lesions, with excellent surgical outcomes.