The pterygium, Autologous conjunctiva-limbus transplantation as treatment]

Based on a new concept of the limbus as a junctional zone for separating the vascularized conjunctiva from the avascular cornea, this study presents conjunctival/limbal autograft transplantation for 22 cases of pterygium. The pterygia were primary in 17 eyes, cicatricial in 1 and recurrent in 4. In all cases a free transplant of the superotemperal limbus with an adjacent piece of thin conjunctiva was placed in the excision area. Postoperative follow-up ranged from 1 1/2 to 17 months, with a mean of 8.7 months. Only two pterygia recurred. In all other cases ideal anatomic reconstruction was achieved without any side effects. The authors believe that conjunctival/limbal transplantation is an encouraging technique for treating a pterygium surgically.     

Stabilisation of diabetic retinopathy following simultaneous pancreas and kidney transplant

BACKGROUND/AIMS: Simultaneous pancreas and kidney transplantation (SPK) has become an important option in selected IDDM patients with end stage renal disease (ESRD). Successful SPK transplants are associated with long term normoglycaemic control and improved quality of life. However, debate still continues on the benefit to patients in terms of stabilisation or amelioration of diabetic retinopathy. The progression of diabetic retinopathy (DR) in a cohort of 20 SPK transplant patients is reported. METHODS: All patients were reviewed postoperatively with corrected visual acuity, slit lamp examination, and fundal biomicroscopy. Preoperative data were collected retrospectively and DR was considered unstable if there had been a drop in Snellen acuity greater than three lines or a need for laser photocoagulation or vitrectomy in the 2 years preoperatively. RESULTS: 20 patients who received SPK transplants between March 1983 and April 1994 were reviewed (mean age 35.1 years; mean duration of IDDM = 24.6 years). 17 patients still had functioning grafts at a mean follow up of 5.1 years. Nine of these patients had unstable DR before transplantation. Of these, 89% (8/9) had stabilised DR following transplantation with only a single case requiring laser photocoagulation. Of the eight patients that had stable DR before transplantation all had stable DR following transplantation. 41% of cases (7/17) required cataract surgery during the follow up period. CONCLUSIONS: Advanced diabetic retinopathy is present in a high proportion of cases managed with SPK transplant as a consequence of the duration of IDDM and the presence of ESRD. More than 90% of cases have stable DR following transplant.     

带角膜缘干细胞的自体结膜瓣移植术治疗复发性翼状胬肉

目的:观察带角膜缘干细胞的自体结膜瓣移植术治疗复发性翼状胬肉的临床有效性和实用性。方法:复发性翼状胬肉患者53例57眼。复发性翼状胬肉切除全部病灶组织后移植带角膜缘干细胞的自体结膜瓣,移植结膜瓣取自术眼上方结膜。结果:术眼57眼术后随访1~12mo,3例出现复发,复发率5%。1例发生角巩膜自溶,并手术治疗。余53眼经1~12mo的随访角膜创面愈合良好,植片全部存活,无明显手术痕迹,治愈率93%。结论:采用自体角膜缘干细胞移植术治疗复发性翼状胬肉,手术取材方便、创面修复快,术后复发率低,满足部分患者美观需求,改善了术后效果,是一种理想的术式,值得基层临床推广应用。     

Survival analysis and visual outcome in a large series of corneal transplants in India

AIM/BACKGROUND—The public health significance of corneal transplantation in dealing with corneal blindness in the developing world would depend upon the survival rate of transplants. This study was done to analyse the survival rate of corneal transplants in a large series in India, and to evaluate the influence of various risk factors on transplant survival.
METHODS—The records of a series of 1725 cases of corneal transplants carried out during 1987-95 at a tertiary eye care institution in India were reviewed. The Kaplan-Meier method was used to determine 5 year survival rates of corneal transplants performed for the various categories of preoperative diagnosis. Multivariate Cox proportional hazards regression was used to assess how preoperative diagnosis, socioeconomic status, age, sex, vascularisation of host cornea, quality of donor cornea, and training status of surgeon influenced transplant survival. The effect of these variables on visual outcome was assessed using multiple logistic regression.
RESULTS—The survival rates at 1, 2, and 5 years for all corneal transplants performed for the first time in 1389 cases were 79.6% (95% confidence interval = 77.3-81.9%), 68.7% (65.7-71.7%) and 46.5% (41.7-51.3%). The 5 year survival rate was highest if the corneal transplant was done for keratoconus (95.1% (84.8-100%)) and lowest if carried out for previous transplant failure (21.2% (13.8-28.6%)). The relative risk of transplant failure was higher if the preoperative diagnosis was previous transplant failure (2.04 (1.62-2.55)), aphakic bullous keratopathy (1.78 (1.38-2.28)), corneal clouding due to miscellaneous causes including congenital conditions and glaucoma (1.63 (1.21-2.19)), or adherent leucoma (1.11 (0.81-1.51)) than for the other preoperative diagnoses. Patients with lower socioeconomic status had higher relative risk of transplant failure (1.28 (1.16-1.42)), as did patients <10 years of age (1.42 (1.23-1.64)). Higher relative risk of transplant failure was associated with vascularisation of the host cornea before transplantation (1.15 (1.04-1.27)), and with the use of fair quality donor cornea for transplantation compared with excellent, very good, or good quality donor cornea (1.26 (1.06-1.52)). Before corneal transplant 80.2% of the eyes were blind (visual acuity <3/60), whereas at last follow up 41.8% eyes were blind. The odds of having visual acuity >6/18 were higher if the transplant was done for keratoconus (9.99 (6.10-16.36)) or corneal dystrophies (1.77 (1.21-2.58)) than for the other preoperative diagnoses.
CONCLUSION—Reasonable success with corneal transplantation is possible in the developing world if data from this part of the world regarding the different survival rates for the various preoperative diagnoses and the influence of risk factors on transplant survival and visual outcome are taken into account while determining priority for transplant cases in the present situation of limited availability of donor corneas.

     

带环形巩膜瓣及角膜缘的全角膜板层移植术治疗蚕蚀性角膜溃疡

目的观察带环形巩膜瓣及角膜缘的全角膜板层移植术治疗蚕蚀性角膜溃疡的临床效果.方法取带宽6mm球结膜和4mm板层巩膜的全角膜板层植片,治疗4例(4只眼)蚕蚀性角膜溃疡.结果 4例蚕蚀性角膜溃疡患者均Ⅰ期愈合,视力提高;随访1～3年,视力为0.2～0.6,无明显基质型排斥反应,也无复发;角膜表面稳定,无上皮糜烂现象,无假性翼状胬肉发生;层间新生血管部分萎缩,2例表层出现不同程度的新生血管.结论带环形巩膜瓣及角膜缘的全角膜板层移植术是治疗蚕蚀性角膜溃疡的有效手段.     

Supratarsal triamcinolone injection in the treatment of superior limbic keratoconjunctivitis

PURPOSE: To evaluate the efficacy of supratarsal triamcinolone injection in the treatment of superior limbic keratoconjunctivitis (SLK). METHODS: Forty eyes of 20 patients were diagnosed with SLK. All eyes with long-standing severe ocular irritation unresponsive to topical steroid and artificial tears were treated with supratarsal triamcinolone injection in addition to ongoing treatment of dry eye. Objective tarsal conjunctiva inflammation, bulbar conjunctiva, cornea staining, and subjective symptom gradings were performed before and after 2 weeks of therapy. All patients underwent laboratory evaluations of underlying systemic abnormalities. RESULTS: All 40 eyes responded well to treatment and had long-term (average, 7.8 months) improvement of irritation and dry sensation and improvement of inflammation and staining of conjunctiva and cornea. Fourteen patients (70%) had associated autoimmune diseases. There were no irreversible complications related to this therapy. CONCLUSIONS: Supratarsal triamcinolone injection effectively and rapidly resolved symptoms and signs associated with SLK. It is helpful as primary or adjunctive therapy for SLK.     

血管膜切除联合羊膜移植治疗复发性免疫性角结膜炎

目的报告局部血管膜切除联合羊膜移植治疗复发性免疫性角结膜炎的初步临床结果。设计回顾性病例系列。研究对象病变反复发作并开始累及角膜、药物控制欠佳的泡性角膜炎患者2例、结节状巩膜炎累及角膜1例、角膜基质炎2例。方法切除局部角巩膜缘部结膜及巩膜表面变性组织,并移植相应大小的羊膜组织。术后局部免疫抑制剂治疗2￣3周,随访6￣12个月。主要指标并发症与复发情况。结果4例患者在停药4￣10个月后无复发,角膜浸润逐渐减轻,血管萎缩。1例结节状巩膜炎患者在术后12个月时病变复发,但仅局限于球结膜部位,角膜病变无复发。结论对于反复发作、病变累及角膜的免疫性角结膜炎,局部球结膜切除联合羊膜移植可以阻止角膜病变的进展。(眼科,2006,15:177-179)     

Cataract formation following corneal transplantation in eyes with Fuchs' endothelial dystrophy

In a retrospective analysis, 78 eyes in 58 patients that underwent corneal transplantation for Fuchs' endothelial dystrophy were examined for the presence of cataracts. Follow-up ranged from 1 to 17 years, with an average of 6.62 years. Thirty-four (44.1%) of the eyes developed cataracts sufficient enough to require surgical removal. The mean time from transplant to cataract formation averaged 4.9 years. The average age at the time of transplant surgery in the eyes that did not develop cataracts was 55.6, and in those that developed cataracts, 60.3 (p = 0.049). Thirteen percent of the transplants lost transparency following cataract extraction. The incidence of postkeratoplasty cataract increased at age 50 and occurred in 75% of eyes grafted in patients 60 years of age or older.     

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.     

Nonpreserved human amniotic membrane transplantation for conjunctival reconstruction after excision of extensive ocular surface neoplasia

PURPOSE: To report our experience on the use of nonpreserved human amniotic membrane transplantation (AMT) in ocular surface reconstruction after excision of extensive ocular surface neoplasia (OSN). DESIGN: Prospective noncomparative interventional case series. PARTICIPANTS: In all, 10 eyes of 10 consecutive patients with extensive OSN involving various areas of limbus, conjunctiva, and cornea (conjunctival carcinoma in situ, four eyes; squamous cell carcinoma, three eyes; malignant melanoma, two eyes; conjunctival-orbital lymphangioma, one eye) were included in this prospective noncomparative interventional case series. After excision of the neoplasia with 3-4 mm tumour-free margins, double freeze-thaw cryotherapy was applied to the margins of the remaining conjunctiva, and nonpreserved human amniotic membrane graft was sutured to the adjacent conjunctiva using 8/0 vicryl sutures and cornea using 10/0 nylon sutures, with the epithelial side facing up to cover the bare sclera and cornea. Postoperatively, topical corticosteroids were used for 3 months. RESULTS: After tumour excision and AMT, a satisfactory result with a wet, stable conjunctiva, and rapid and complete healing was observed in all eyes. Over a mean follow-up of 10.0 months (range, 6-27 months), all but one eye remained free of tumour recurrence. In one eye with conjunctival melanoma, there was a small recurrence, which was treated with excision and cryotherapy. Treatment complications were partial stem cell deficiency in two eyes and symblepharon formation in one eye. Immune graft rejection was not encountered. CONCLUSION: Nonpreserved human AMT appears to be useful for reconstruction of ocular surface following excision of extensive OSN.     

自体角膜缘移植联合球结膜移植治疗翼状胬肉

目的探讨治疗巨大翼状胬肉及复发性翼状胬肉的有效方法。方法对27例(27眼)巨大翼状胬肉及复发性翼状胬肉行胬肉切除加自体球结膜移植或自体角膜缘移植联合球结膜移植术。Ⅰ组8例(自体球结膜移植组)翼状胬肉单纯切除后取同眼颞上方球结膜移植于巩膜暴露区,Ⅱ组19例(自体角膜缘移植联合球结膜移植组)翼状胬肉单纯切除后取同眼颞上方结膜角膜缘上皮组织移植于巩膜暴露区。所有病例均在手术显微镜下操作。结果术后平均随访9.4月,自体球结膜移植组复发1例,自体角膜缘移植联合球结膜移植组未见复发。结论自体角膜缘移植联合球结膜移植治疗翼状胬肉疗效良好。     

静吸复合麻醉下行婴儿角结膜皮样瘤摘除术

目的:观察静吸复合麻醉下行婴儿角结膜皮样瘤摘除术的临床效果。方法:18例年龄为1～6(平均3.8)mo的儿童角结膜皮样瘤行皮样瘤单纯切除术,术区用结膜或羊膜覆盖。麻醉采用静吸复合麻醉,术前肌注阿托品0.02mg/kg,诱导麻醉:本组药物均用咪唑安定0.1mg/kg,氯胺酮0.1mg/kg,万可松0.1mg/kg静脉注入快速诱导麻醉;麻醉维持:吸入10～150g/L异氟醚以及异丙酚静脉泵注。结果:18例均位于眼球颞侧角膜缘,无1例伸入角膜中央。麻醉期间患儿呼吸循环各项指标均正常,且无任何并发症发生,术毕迅速苏醒。术后随访6mo～5a,17例治愈,达到无并发症愈合,仅1例复发。结论:6mo以内在静吸复合麻醉下行婴幼儿角结膜皮样瘤摘除术值得提倡。     

Keratoplasty with stored tissue. Initial results of a prospective study]

The first results of a prospective study on 50 patients who were followed up 2, 4, 6, and 12 months after keratoplasty are reported. The patients received a human cornea transplant, which had been cultured in a modified MEM medium for up to 28 days. We observed that the loss of epithelium during organ culture leads to delayed regeneration after keratoplasty. This is especially important for patients who have had this problem almost before transplantation. The slower increase of visual acuity after keratoplasty with organ-cultured material is due to increased folding of Descemet's membrane. Nevertheless the best vision was usually reached within 6 to 12 months. We saw seven immune reactions by which five transplants were lost. A comparatively low rejection rate was observed especially in the group of high-risk patients (27.2%). Organ culture may therefore have some additional positive effects for these patients.     

新鲜羊膜移植治疗早期重症眼部烧伤

目的 探讨新鲜羊膜移植联合结膜、角膜移植对早期重症眼部烧伤的治疗效果。方法 急性重症眼部烧伤患者21例22眼，分别行羊膜移植联合结膜移植12例12眼和羊膜、结膜移植联合板层或穿透性角膜移植9例10眼。术后观察羊膜、结膜及角膜植片情况，长后随访2～16个月，平均7个月。结果 19眼羊膜植片愈合良好；20眼穹隆部结膜植片全部存活；羊膜移植联合结膜移植中10眼术后未见角膜融解，角膜缘均未见新生血管长入。羊膜、结膜移植联合板层或穿透性角膜移植，1例2眼出现轻度排斥反应，另8眼角膜植片均恢复透明。结论 新鲜羊膜移植可有效地促进上皮细胞分化移行、抑制局部的炎症反应、阻止新生血管和瘢痕形成、阻止烧伤的病理发展减轻和推迟角膜植片的排斥反应。     

Report on renal transplant patients. Ocular changes due to renal disease and immunosuppressive therapy (author's transl)]

51 patients with renal transplants were examined ophthalmologically 31,1 (1--77) months after the transplantation. 80,4 p. c. showed ocular complications: cataract formation in 43,1 p. c. of the patients examined and increased intraocular pressure values between 22 and 30 mm Hg in 3 patients are to be attributed to the systemic immunosuppressive therapy. Further ocular changes were recurrent subconjunctival haemorrhages due to increased vascular rigidity, calcium phosphate deposits in the conjunctiva due to persistant secondary hyperparathyroidism and fundus changes (pigmentary irregularities in the foveal regions, narrow arterial vessels). Although marked arterial hypertension was observed in 21 patients after the transplantation, no signs of hypertensive retinopathy could be found. Despite the high incidence of ocular complications after renal transplantation the risks of immunosuppressive therapy must be considered as tolerable: cataract formation and increased intraocular pressure do not impair the positive effect of renal transplantation on ocular functions. Regular ophthalmological control examinations of renal transplant patients are advisable.     

Mechanisms of corneal graft rejection: the sixth annual Thygeson Lecture, presented at the Ocular Microbiology and Immunology Group meeting, October 21, 2000

The history of corneal transplantation reaches back over 150 years. Kissam performed one of the first penetrating keratoplasties when he transplanted a pig cornea onto a human in 1838. Only two interrupted sutures were used, and the surgery was performed without anesthesia! In retrospect, no one would be surprised to learn that the porcine corneal xenograft was rejected. Thirty years later, May transplanted rabbit corneal grafts to humans, but concluded that the failures in the first 24 attempts were the result of "imperfect technique and the inability to keep the eyes properly bandaged." The first documented report of a successful penetrating keratoplasty in a human subject was performed by Zirm in 1905. As we enter the new millennium, corneal transplantation remains the oldest, most common, and, arguably, the most successful form of solid tissue transplantation. In the United States alone, approximately 36,000 corneal transplants are performed each year. The success rate for corneal transplants is in excess of 90% in uncomplicated cases, even though HLA tissue typing is not performed and systemic immunosuppressive drugs are not administered. In spite of this extraordinary success, immune rejection remains the leading cause of corneal graft failure. Many inferences about the immunobiology of corneal graft rejection have been based on clinical observations; however, confirmation of these hypotheses requires prospective studies under controlled settings. The prudent use of animal models has fostered analytic studies on the immunobiology of corneal allografts without the complicating and confounding effects of topical steroids that are typically used on most keratoplasty patients. Although animal models of penetrating keratoplasty have been in use for almost a half-century, until recently, progress in understanding the immune mechanisms of corneal graft rejection has been slow. However, the widespread use of rodent models of orthotopic corneal transplantation has shed new light on the pathogenesis of corneal graft rejection.     

Donor age as a predictor of cornea transplant success

BACKGROUND: The purpose of this study was to examine the association between donor age and cornea transplant success. METHODS: This retrospective cohort study comprised 116 patients who had cornea transplants performed for the first time. The primary analysis was performed to evaluate the time to graft failure as a function of donor age. Donor age was divided into 3 categories: (1) continuous, (2) younger than 65 versus 65 years and older, and (3) younger than 60 versus older than 70 years. We controlled for other variables that may affect graft outcome by multivariate modeling. The primary outcome was graft failure. RESULTS: No statistically significant association was found between time to failure and donor age [adjusted hazard ratio: 1.004 (p = 0.68) for continuous age, 1.18 (p = 0.68) for age < 65 vs. > or = 65 years, and 2.10 (p = 0.089) for age < 60 vs. > 70 years]. However, with all model-building strategies, our results demonstrated that all hazard ratios calculated were greater than 1.00 for the older versus the younger aged groups. INTERPRETATION: The influence of donor age on success of cornea transplants remains unresolved. Large, multicentre prospective cohort studies and randomized trials are needed to decisively determine the impact of donor age on cornea transplant success.     

Corneoscleral rim cultures: lack of utility and implications for clinical decision-making and infection prevention in the care of patients undergoing corneal transplantation

PURPOSE: To assess the utility of donor corneoscleral rim cultures. METHODS: A retrospective review of the culture results of 774 corneoscleral rims that remained after trephination of corneas for transplantation into patients at our academic medical center between January 1992 and November 1997. RESULTS: Forty-one (5.3%) corneoscleral rim cultures yielded microorganisms, mostly coagulase-negative staphylococci. Two patients developed endophthalmitis (one with Staphylococcus aureus and one with Pseudomonas aeruginosa) within 3 months after transplantation; each had a negative corneoscleral rim culture and neither patient's infection was temporally related to the transplant procedure. CONCLUSIONS: Preoperative donor corneoscleral rim cultures are unreliable predictors of endophthalmitis complicating corneal transplantation and, therefore, are not useful in the clinical management of patients having corneal transplants. Moreover, the discrepancy between the results of corneoscleral rim cultures and subsequent endophthalmitis renders them invalid as a quality assurance procedure. Instead, for patients with suspected endophthalmitis after corneal transplantation, we recommend that corneal surgeons select antimicrobial therapy based on current guidelines and the results of directed sampling. Furthermore, eye banks should prospectively track recipients who develop clinical endophthalmitis, immediately notify the corneal surgeon who transplanted the matched cornea of that used for the index case, and, in selected situations, attempt to identify a possible source of contamination.     

翼状胬肉显微切除联合丝裂霉素C加自体带角膜缘上皮结膜移植术观察

目的 探讨翼状胬肉显微手术方法,观察翼状胬肉切除联合应用丝裂霉素C(MMC)加自体带角膜缘上皮的结膜移植术治疗翼状胬肉的疗效。方法 对1251例1326只眼,在手术显微镜下剖切分离球结膜与病变组织,切除胬肉并做广泛的变性球筋膜切除,在结膜下放置0.2 mg/ml的MMC棉片,彻底冲洗后将同侧眼颞上方带有角膜缘上皮的结膜瓣移植到胬肉处的巩膜上。术后随访12～72月,平均27.5月,观察复发情况。结果 术后反应轻,移植片存活,37只眼复发,复发率为2.79％。结论 翼状胬肉显微手术切除联合应用丝裂霉素C加自体带角膜缘上皮的结膜移植术,术后复发率低,是一种安全、有效的方法。     

羊膜移植结膜囊成形术的疗效观察

目的探讨羊膜移植结膜囊成形术中的疗效。方法36例（36眼）结膜囊成形术,包括16眼结膜缺损,行单纯羊膜移植术;8眼睑球粘连涉及角膜或角膜有大量新生血管,行羊膜移植联合板层角膜移植术;12眼行羊膜移植联合结膜穹隆成形。术后随访6～12个月。结果无1例感染。术后10d,移植的羊膜透明,缝合处结膜向羊膜上爬行;术后1个月新生的结膜上皮完全覆盖移植区。36眼治愈14眼,好转19眼,无效3眼。结论羊膜移植是修补结膜囊的一种有效方法。