Clinical,histological and immunohistochemistry characteristics of cornea in the sequelae stage of chronic vernal keratoconjunctivitis

Purpose:To report the clinical outcomes and histopathological and immunohistochemistry (IHC) features in eyes with the sequelae stage of vernal keratoconjunctivitis (VKC).Methods:Investigative study of corneal samples obtained following surgical intervention for vision restoration in four eyes of three patients with VKC. Patient 1 (an 11-year-old boy) had deep anterior lamellar keratoplasty in both eyes, Patient 2 (a 24-year-old male) underwent superficial keratectomy followed by penetrating keratoplasty, and Patient 3 (a 22-year-old male) underwent penetrating keratoplasty. The corneal samples retrieved after surgical intervention were assessed for histology features and immunohistochemistry (IHC) studies.Results:The grafts were clear till the follow-up of 2–18 months. Histopathology of all four corneal samples showed epithelial hyperplasia, absent Bowman layer, thick hyalinized stromal lamellae, vascularization, and chronic inflammatory cells such as lymphocytes and plasma cells. IHC showed strong expression of CK 3 in both eyes of Patient 1 and no expression in Patients 2 and 3. The marker for limbal stem cells, ABCG2, was absent in all four samples; however, p63α was expressed strongly in Patients 2 and 3, moderately in the right eye of Patient 1, and marginally expressed in the left eye of Patient 1.Conclusion:The eyes in the sequelae stage of VKC (having corneal scarring and 360° hypertrophied limbus) can be managed favorably with keratoplasty and amniotic membrane transplantation without allogenic/cadaveric stem cell transplantation. The expression of transient progenitor cells in the scarred corneas of VKC patients in the sequelae stage suggests that the limbal stem cell dysfunction is more likely partial and self-renewal of limbal stem cells is a plausibility in these eyes.     

Recurrent shield ulcer following penetrating keratoplasty for keratoconus associated with vernal keratoconjunctivitis

Though penetrating keratoplasty for keratoconus secondary to vernal keratoconjunctivitis (VKC) invariably carries a good prognosis, the postoperative course may be complicated by recurrent epitheliopathy. Despite good medical control of VKC shield ulcer is still a possibility.     

新鲜人羊膜移植在重建眼表结构中的临床应用

目的：评价新鲜羊膜移植手术在眼表结构重建中的临床效果。方法：对76例不同眼表疾病采用新鲜人羊膜移植手术以重建眼表结构，其中2例眼球碱烧伤角膜缘干细胞严重缺乏角膜溃疡，8例为大泡性角膜炎，4例为真菌性角膜炎，1例严重睑球粘连，61例翼状胬肉（4例为复发性）。结果：术后均未见新鲜羊膜植片急性排斥反应。碱烧伤的2眼，无角结膜进行性溶解和穿孔，无新生血管或假性胬肉侵入角膜表面。大泡性角膜炎，症状均消失；真菌性角膜炎，溃疡全部痊愈。61例翼状胬肉4例复发。结论：新鲜羊膜移植重建角结膜表面，减轻了炎症反应，减少新生血管的生成，抑制纤维组织增生。充分清除眼表的病变组织和羊膜移植片的缝合固定，对羊膜移植重建眼表结构，恢复功能极其重要。     

Incidence of keratoconus in subjects with vernal keratoconjunctivitis: a videokeratographic study

PURPOSE: To detect the incidence of keratoconus by videography in patients with vernal keratoconjunctivitis (VKC) and to evaluate the clinical characteristics of VKC associated with keratoconus. DESIGN: a prospective, cross-sectional (prevalence) study. PARTICIPANTS: Eighty-two consecutive subjects with the diagnosis of VKC. METHODS: Both eyes of VKC subjects were investigated by videokeratography in comparison with slit-lamp biomicroscopy and keratometry. To detect keratoconus, corneal topography maps were examined with modified Robinowitz-McDonnell test. MAIN OUTCOME MEASURES: In this test, maps with central corneal power greater than 47.2 diopters and/or the inferosuperior asymmetry value greater than 1.4 were considered to have a keratoconus pattern. The findings of VKC were also recorded, RESULTS: The distribution of clinical forms of VKC were as follows: 46.34% mixed, 43.90% palpebral, and 9.76% limbal types. Twenty-six (31.7%) of 82 subjects had complications with keratopathy such as pseudo-genontoxon, punctate keratitis, and shield ulcer. Forty-four eyes (26.8%) were detected as keratoconus by quantitative evaluation of videokeratography maps. 14 eyes (8.5%) by biomicroscopy, and 30 eyes (18.3%) by keratometry. The increased incidence of keratoconus was associated with male gender, long-standing disease, mixed and palpebral forms, and advanced corneal lesions. CONCLUSIONS: The higher incidence of keratoconus in our study compared with the previous reports may result from early detection of mild keratoconus by interpretation of color-coded videokeratographic maps with a sensitive quantitative method.     

In vivo survival and stratification of cultured limbal epithelium

A 6-year-old Bangladeshi girl presented with total limbal stem cell deficiency in the left eye, secondary to a 6-month-old chemical injury. The patient had also previously undergone two limbal transplantation surgeries. At the authors' centre the child underwent autologous cultured limbal epithelium transplantation, on human amniotic membrane, without the use of air-lift technique. Symptomatic relief, re-epithelialization of the ocular surface, regression of corneal pannus and slight improvement in vision were all noted. The corneal button obtained at the time of keratoplasty (performed 4 months later) revealed stratified epithelium with basement membrane. Thirty-seven months post keratoplasty, the best-corrected visual acuity was 6/15 with clear graft and stable ocular surface. Herein, a case of limbal stem cell deficiency successfully managed by monolayer of cultured limbal epithelium is presented.     

Long-term effectiveness of autologous cultured limbal stem cell grafts in patients with limbal stem cell deficiency due to chemical burns

Background: Chemical burns cause depletion of limbal stem cells and eventually lead to corneal opacity and visual loss. We investigated the long‐term effectiveness of autologous cultured limbal stem cell grafts in patients with limbal stem cell deficiency. Design: Prospective, non‐comparative interventional case series. Participants: Sixteen eyes from 16 patients with severe, unilateral limbal stem cell deficiency caused by chemical burns. Methods: Autologous ex vivo cultured limbal stem cells were grafted onto the recipient eye after superficial keratectomy. Main Outcome Measures: Clinical parameters of limbal stem cell deficiency (stability/transparency of the corneal epithelium, superficial corneal vascularization and pain/photophobia), visual acuity, cytokeratin expression on impression cytology specimens and histology on excised corneal buttons. Results: At 12 months post‐surgery, evaluation of the 16 patients showed that 10 (62.6%) experienced complete restoration of a stable and clear epithelium and 3 (18.7%) had partially successful outcomes (re‐appearance of conjunctiva in some sectors of the cornea and instable corneal surface). Graft failure (no change in corneal surface conditions) was seen in three (18.7%) patients. Penetrating keratoplasty was performed in seven patients, with visual acuity improving up to 0.8 (best result). For two patients, regeneration of the corneal epithelium was confirmed by molecular marker (p63, cytokeratin 3, 12 and 19, mucin 1) analysis. Follow‐up times ranged from 12 to 50 months. Conclusions: Grafts of autologous limbal stem cells cultured onto fibrin glue discs can successfully regenerate the corneal epithelium in patients with limbal stem cell deficiency, allowing to perform successful cornea transplantation and restore vision.     

Penetrating keratoplasty and keratolimbal allograft transplantation for corneal perforations associated with the ectodermal dysplasia syndrome

PURPOSE: To report two patients with ectodermal dysplasia-associated keratopathy treated with keratolimbal allograft transplantation and penetrating keratoplasty.METHODS: Two patients with ectodermal dysplasia suffered multiple corneal perforations. In both patients, keratolimbal allograft transplantation was performed along with penetrating keratoplasty. Histopathology of the corneal buttons was obtained. RESULTS: Histopathologic examination showed chronic inflammation with thin, irregular epithelium, loss of stromal tissue, and thin or absent Bowman's membrane. Both patients had multiple contributing factors predisposing them to corneal perforations including an inherent ectodermal defect, trichiasis, poor tear film, and limbal stem cell deficiency. CONCLUSIONS: Patients with keratopathy and corneal perforations associated with the ectodermal dysplasia syndrome has a poor prognosis. Keratolimbal allograft transplantation may have a role in the treatment of this disease. Longer follow-up and additional case reports will determine whether this technique confers a better prognosis than keratoplasty alone.     

Adult keratoplasty: has the prognosis improved in the last 25 years?

Adult keratoplasty outcomes have significantly improved in the past quarter century as a result of new pharmaceuticals, advanced surgical devices, better understanding of what causes graft failure, and targeted techniques for selective replacement of only diseased corneal layers. Prevention and treatment of graft rejection, which has long been a leading cause of graft failure, has improved with the development of innovative topical and systemic immuno-suppressants. New methods for preventing and treating ocular surface complications have been devised, and limbal stem cell grafts have significantly improved management of severe ocular surface disease. Improved intraocular lens designs cause less corneal damage and have increased corneal graft survival. Non-steroidal anti-inflammatory (NSAID) eyedrops and more complete vitrectomies have reduced the incidence of chronic cystoid macular edema, which could prevent eyes with clear grafts from regaining useful vision. Patients with keratoconus or corneal scars can now benefit from advanced anterior lamellar keratoplasty techniques, which reduce the risk of immunologic rejection and endothelial failure, while matching the visual outcomes achieved with penetrating keratoplasty. Patients with endothelial dysfunction can now benefit from advanced endothelial keratoplasty techniques, which provide more rapid visual recovery, minimize induced astigmatism and ocular surface problems, and virtually eliminate the risk of wound rupture from minor trauma. Finally, femtosecond lasers now provide transplant surgeons with a precise tool for creating complex, interlocking corneal incisions that may facilitate wound healing.     

Sulfur mustard-induced ocular surface disorders

Sulfur mustard is a vesicant agent with severe irritating effects on living tissues, including skin, mucous membranes, eyes, and respiratory tract. The eyes are the most susceptible tissue to mustard gas effects, and varying degrees of ocular involvement are seen in 75% to 90% of exposed individuals. Most cases resolve uneventfully; however, a minority of exposed patients will have a continuous process, which manifests clinically either as a persistent smoldering inflammation (chronic form) or late-onset lesions appearing many years after a variable "silent" period (delayed form). Distinctive features common to most cases with chronic involvement include chronic blepharitis, meibomian gland dysfunction, dry eye, limbal ischemia, limbal stem cell deficiency, aberrant conjunctival vessels, corneal neovascularization, and secondary degenerative changes, including lipid and amyloid deposition and corneal irregularity, thinning and scarring. Most cases can be managed with conservative measures, eg, preservative-free artificial tears, lubricants, and topical steroids. Punctal plugs or punctal cauterization is helpful in moderate and severe forms of injury. Surgical modalities, including lateral or medial tarsorrhaphies, amniotic membrane transplantation, lamellar or penetrating keratoplasty, and stem cell transplantation have been used.     

活体异体结膜缘和羊膜移植治疗化学性眼外伤造成的角膜缘干细胞缺失(英文)

目的:评价利用活体异体结膜缘和羊膜移植治疗化学性眼外伤造成的角膜缘干细胞缺失的临床效果。方法:从2005-07/2007-12,本研究包括了9名男性化学性眼外伤患者(10眼)。所有患者接受了亲属活体异体结膜缘和羊膜移植,2例眼接受了睑缝术。用环孢菌素和泼尼松龙进行全身性免疫抑制。结果:在3例眼中观察到完全角膜上皮化(30%),其中1例在术后1.5mo出现免疫排斥,角膜溶解引起穿孔,加大全身性免疫抑制剂量来控制病情。3例眼中植片无法在角膜表面重新形成上皮,被定为原发性失败。其余4眼有部分上皮形成,但上皮细胞无法完全覆盖角膜表面。术前最佳矫正视力从手动到1m处数指,术后最佳矫正视力从光感到20/80。有5眼视力得到改进,不需其他治疗。手术失败的主要原因为干眼症和持续性炎症。结论:对于能控制泪量和眼部炎症的病例,亲属活体异体角膜缘和羊膜移植是治疗化学性眼外伤造成的角膜缘干细胞缺失最佳方法之一。     

Ipsilateral limbal translocation for treatment of partial limbal deficiency secondary to ocular alkali burn

BACKGROUND/AIM: Chemical ocular burn, especially by alkali, may result in damage to the limbal stem cells, fundamental in maintaining the integrity of ocular surface. Clinically, patients manifest abnormal conjunctival-corneal healing with peripheral neovessels, chronic epithelial defect, severe stromal inflammation, and conjunctivalisation of the corneal, which is characteristic of limbal deficiency. Penetrating keratoplasty has a poor prognosis in these cases. Available therapeutic options included limbal autograft and allograft transplantation associated or not with human amniotic membrane transplant. The authors propose an alternative treatment with ipsilateral autologous limbal transplantation, transferring the healthy portion of the limbus from the partially burned eye to the deficient area in patients with partial limbal deficiency secondary to alkali burn. METHODS: Ipsilateral limbal autografts were performed in five patients with partial limbal deficiency secondary to alkali burn, transferring the healthy portion of the limbus to the burned area of the same eye, without intervening in the contralateral eye. RESULTS: All cases had regression of the limbal deficiency with improvement of visual acuity to a minimum of 20/60-20/20 (partial), without complications during the follow up period (range 7-11 months). CONCLUSION: Ipsilateral autologous limbal autograft is a therapeutic option for partial limbal deficient eyes.     

<Emphasis Type="Italic">Aspergillus keratitis</Emphasis> in vernal shield ulcer—a case report and review

An unusual case of vernal shield ulcer with superadded fungal keratitis caused by Aspergillus fumigates is reported. A 26-year-old man, a known case of vernal keratoconjunctivitis (VKC) presented with the complaint of diminution of vision in the right eye. Patient was on topical steroids and anti-allergic treatment for the past two months. In the right eye, a shield ulcer with an elevated plaque was seen. Scrapings from the right cornea revealed fungal filaments on a wet KOH mount and culture revealed growth of Aspergillus fumigatus. The patient was diagnosed as VKC with shield ulcer with secondary fungal keratitis. The patient was treated with topical cyclosporine, topical moxifloxacin, topical natamycin, and topical amphotericin eye drops. The patient responded well and finally recovered to a best spectacle-corrected visual acuity of 20/20 at the end of nine months. The chronic ocular surface changes and induced inflammation in VKC, and the instillation of topical steroids for therapy, may create an environmental milieu favorable for fungal keratitis. Microbiological evaluation should be considered, even in cases of suspected sterile keratitis, to prevent possible worsening of an associated infective corneal condition. This warrants patient education, periodic reviews and a very cautious approach to indiscriminate use of topical corticosteroids in cases of VKC with shield ulcer. In the event of any secondary fungal infection, use of steroid sparing topical agent, for example cyclosporine may be considered.     

Amniotic membrane transplantation for partial limbal stem cell deficiency

AIM: To examine the efficacy, safety, and long term outcomes of amniotic membrane transplantation for corneal surface reconstruction in cases of partial limbal stem cell deficiency. METHODS: 17 eyes of 15 patients with partial limbal stem cell deficiency underwent superficial keratectomy of the conjunctivalised corneal surface followed by amniotic membrane transplantation. Cases were followed up for at least a year. RESULTS: All eyes exhibited a stable, intact corneal epithelial surface after a mean follow up period of 25.8 months with no eyes developing recurrent erosion or persistent epithelial defect. The mean time to re-epithelialisation was 22.8 days. Overall improvement in visual acuity was observed in 92.9% of 14 eyes with visual potential. Of those, five eyes gained six or more lines, two eyes gained between four and five lines, six eyes gained between one and three lines, and one eye lost three lines of Snellen acuity. Pain and photophobia were abolished in 86% of cases and substantially reduced in 14%, with all eyes exhibiting decreased vascularisation and inflammation at final follow up. CONCLUSIONS: Amniotic membrane transplantation appears to be a safe and effective method of restoring a stable corneal epithelium for cases of partial limbal stem cell deficiency and can be considered as an alternative to limbal autograft or allograft.     

前房冲洗在严重前房积脓性角膜溃疡的角膜移植术中应用

目的 探讨感染性角膜溃疡伴有大量前房积脓患者于角膜移植术前行前房冲洗的临床意义.方法 回顾性系列病例研究.2008年1月至2009年6月于山东省眼科医院接受手术的角膜溃疡伴有严重前房积脓的患者20例(20只眼),前房积脓均超过3 mm,其中13例患者伴有明显的角膜内皮斑,术前裂隙灯显微镜下病灶边缘难于判断.对20例患者采用前房穿刺冲洗联合穿透或板层角膜移植手术治疗.供体采用角膜中期保存液保存或甘油干燥冷冻保存.对术中与术后并发症、视力、免疫排斥反应等进行观察,随访时间术后6～12个月.结果 20例患者均成功行前房穿刺冲洗联合角膜移植手术,其中11只眼行穿透性角膜移植,9只眼行板层角膜移植.10例接受穿透性角膜移植的患者采用角膜中期保存液保存的供体角膜,其余10例患者采用甘油脱水冷冻保存的供体角膜.术中并发症主要为虹膜出血(11例),术后并发症主要包括部分虹膜后粘连(8例)、一过性眼压高(4例)、前房积血(5例),药物治疗均缓解.真菌复发1例,行扩大病灶切除再次穿透性角膜移植手术后感染控制.4例患者发生内皮型免疫排斥反应,3例抗排斥治疗后控制,1例发生植片混浊.至2009年12月最后随访,9例接受角膜中期保存液保存角膜供体患者的植片透明,1例植片水肿混浊;8例接受甘油脱水冷冻保存角膜供体患者的植片透明,2例植片水肿.结论 常规角膜移植前行前房穿刺冲洗,对严重前房积脓性角膜溃疡病灶边缘的判断和手术方式选择具有重要意义,可以提高手术的安全性.     

Limbal autograft transplantation, eight consecutive cases

BACKGROUND: Limbal autograft transplantation is the procedure of choice in the management of ocular surface disorders secondary to stem cells deficiency. The aim of our study was to investigate the indications, results and limits of this infrequent surgery. METHODS: Limbal autograft transplantation was performed in 8 patients and the mean follow-up period was 11 months. Limbal stem cell deficiency was due to chemical burns in 4 patients, history of prior surgery extending to the limbus in 2 patients, chronic limbitis with dystichiasis in one patient and persistent corneal epithelial defect after keratoplasty in one case. RESULTS: In 6 out of 8 cases, the stability of the ocular surface normalized and comfort significantly improved. Four of these patients had increased visual acuity after surgery. Two patients who presented with severe alkali burn did not respond well to limbal autotransplantation. CONCLUSION: Limbal autograft transplantation is a reliable and effective procedure in limbal stem cells deficiencies. New associate procedures such as amniotic membrane transplantation will however be necessary to improve the prognosis of very severe corneal surface disorders.     

Demographic and clinical profile of vernal keratoconjunctivitis at a tertiary eye care center in India

Purpose:

To study the demographic and clinical profile of patients with vernal keratoconjunctivitis (VKC) at a tertiary eye care center in India.

Materials and Methods:

Retrospective chart analysis of 468 patients of VKC seen from January 2006 to December 2006.

Results:

Mean age at presentation was 12 years. Majority of the patients had mixed pattern disease (72%). Chronic perennial disease was seen in 36% patients. Personal or family history of allergies was noted in 5% patients. Severe disease based on clinical grading was present in 37% patients. Moderate to severe vision loss was seen in 12% of total population. Persistent disease beyond 20 years of age was found in 12% patients. VKC-related complications such as corneal scarring (11%), shield ulcer (3%), keratoconus (6%), and limbal stem cell deficiency (1.2%) were seen. Treatment-related complications like corticosteroid-induced cataract and glaucoma were seen in 6% and 4% of patients, respectively.

Conclusion:

Clinical pattern of VKC seen in the tropical climate of India is essentially similar to that seen in other tropical countries. Few distinct features that we noted represent chronic perennial disease, low association with atopy, and higher propensity for disease and treatment-related complications.     

角膜塑形术致感染性角膜溃疡的临床分析

目的分析总结16例角膜塑形术(orthokeratology,OK)镜治疗过程中发生的绿脓杆菌、真菌和棘阿米巴性角膜溃疡的临床过程、治疗经过及转归.方法根据感染病原微生物的不同,用微生物学方法对16例行OK镜治疗致角膜溃疡患者进行检测,采取不同的敏感药物治疗,对9例角膜感染严重、药物治疗不能控制或濒于穿孔的患者,行板层或穿透性角膜移植术.总结并分析其临床转归及治疗效果.结果 16例中,角膜刮片细长杆菌7例,棘阿米巴7例,真菌1例,未检出1例.角膜溃疡刮片培养铜绿假单胞菌7例,棘阿米巴7例,真菌1例,未检出致病菌者1例.治疗药物治疗7例,板层角膜移植术6例,穿透性角膜移植术3例.治疗后视力＞0.1者7例,0.02～0.1者4例, ＜0.02者5例.结论感染性角膜溃疡是OK治疗近视最严重的并发症,应积极抗感染治疗,必要时应及时行角膜移植术.虽然最终感染可得以控制,但明显损害患者视力.     

干燥保存角膜片在真菌性角膜溃疡手术治疗中的作用

目的 评价干燥保存角膜片在真菌性角膜溃疡手术治疗中的作用。方法 对５４例（５４只眼）药物治疗无产儿的真菌性角膜溃疡患者采用无在油蔌无水氯化钙保存的角膜片,分别行板有膜移植术及穿透性角膜移植术后治疗,术中分别以５％碘酊烧灼植床表面及氟康唑原液或移植液冲洗前房,以观察其治疗效果。结果 板层角膜移植组２３例,１镒手术成功者１８例,２次手术成功者３例、手术成功率为９１．３％２例术后角膜炎复发,改行穿性角膜     

Impression cytology-proven corneal stem cell deficiency in patients after surgeries involving the limbus

PURPOSE: To report three cases of limbal stem cell deficiency (confirmed by impression cytology) that followed multiple pterygium surgeries and therapeutic penetrating keratoplasty. METHODS: The first case, after multiple pterygium surgeries, presented with corneal scarring and thickened epithelium with vascularization sparing the central cornea in the right eye and involving the entire cornea in the left eye. The second case presented with superficial scarring and extensive vascularization after failed therapeutic graft performed for a large perforated corneal ulcer. The third case was a clear graft performed for a progressing fungal ulcer with signs of conjunctivalization inferotemporally. Limbal stem cell deficiency was clinically suspected in all of these cases. RESULTS: Goblet cells with mucin globules were found on the corneal surface by impression cytology in all three cases. CONCLUSIONS: We report three cases of limbal stem cell deficiency (proven by impression cytology) that followed multiple pterygium surgeries and therapeutic penetrating keratoplasty. Surgical insult to the limbus is the predisposing factor for stem cell damage in these cases. Involvement of the limbus by infection and use of intensive medications are probable contributing factors for stem cell damage in cases of therapeutic penetrating keratoplasty.     

翼状胬肉切除术后角膜溃疡46例临床分析

目的：分析翼状胬肉切除术后角膜溃疡的临床特征，探讨其治疗方案。方法：回顾性系列病例研究。收集2004年1月至2020年12月就诊于山东省眼科医院的继发于翼状胬肉切除术后的角膜溃疡患者46例（46眼）。仔细追溯患者术前全身及局部病史，翼状胬肉切除的手术方式及术后处理等，记录角膜溃疡病变的大小、位置、深浅，角膜缘干细胞是否受损，有无睑球粘连，有无巩膜缺血及熔解，有无病原学感染等。观察患者角膜溃疡的治疗方法及愈后情况。数据采用Wilcoxon秩和检验、卡方检验等非参数检验进行分析。结果：26例行单纯翼状胬肉切除术，17例翼状胬肉切除术中行联合自体干细胞移植术，仅1例术中联合使用抗代谢药物。病原学检测显示无菌性角膜溃疡26例（57%），感染性角膜溃疡20例（43%）。溃疡中心多位于原胬肉附着处，32例累及角巩膜缘，10例合并严重巩膜缺血、坏死。36例患者行穿透性角膜移植和（或）板层角膜移植手术治疗；7例接受包括羊膜移植术、结膜瓣遮盖术、角膜病灶切除术在内的非角膜移植手术治疗；3例患者单纯药物治疗后痊愈。其中非感染性角膜溃疡20例术中联合自体干细胞移植术，感染性角膜溃疡11例将附近结膜移行覆盖。溃疡愈合后最佳矫正视力较治疗前明显提高（Z=-5.901，P<0.001）。结论：继发于翼状胬肉切除术后的角膜溃疡多发生于胬肉附着处，常伴有睑球粘连、巩膜缺血坏死。彻底清除局部病灶，恢复角膜的完整性及改善角膜缘干细胞功能是治疗角膜溃疡的关键。