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Tischer N, Zemova E, Maamri A, Pfeiffer M, Reinert U, Sideroudi H, Seitz B. [Immune reaction after penetrating keratoplasty depending on graft size and centration]. DIE OPHTHALMOLOGIE 2023; 120:36-42. [PMID: 35925343 DOI: 10.1007/s00347-022-01672-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 05/20/2022] [Accepted: 05/24/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND Immune reaction (IR) after penetrating keratoplasty (PKP) is a serious complication with a high risk of graft failure. The aim of this study was to analyze and evaluate the risk factors for IR, in particular, the influence of graft size and centration. PATIENTS AND METHODS A total of 2133 patients who underwent PKP between January 2009 and July 2019 were included in this retrospective study. The following endpoints were analyzed: frequency of IR, graft origin, donor and patient age, diagnosis, corneal diameter and ratio of the graft size to the recipient cornea size. In addition, the role of graft centration, with the help of distance measurements of the graft margins to the vascularized limbus at four locations, was investigated in detail. RESULTS Overall, 8.25% of patients suffered from IR during the observational period. The frequency of IR was significantly correlated (p < 0.001) with the ratio of the graft size to the recipient cornea size. In addition, a statistically significant correlation was found between the occurrence of IR and a small distance to the limbal margins in the Y‑axis (inferior and superior). In particular, the correlation coefficient was larger at the inferior limbus (p < 0.001). CONCLUSION An IR after PKP is a not uncommon complication and is significantly related to graft size and centration. A large graft chosen in relation to the recipient cornea and the proximity of the graft to the vascularized limbus at the inferior and superior sites significantly correlate with the occurrence of IR. These are important risk factors for graft survival, which can be influenced by the corneal microsurgeon and could possibly be further optimized in the future.
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Affiliation(s)
- N Tischer
- Klinik für Augenheilkunde, Universitätsklinikum des Saarlandes (UKS), Homburg/Saar, Deutschland.
| | - E Zemova
- Klinik für Augenheilkunde, Universitätsklinikum des Saarlandes (UKS), Homburg/Saar, Deutschland
| | - A Maamri
- Klinik für Augenheilkunde, Universitätsklinikum des Saarlandes (UKS), Homburg/Saar, Deutschland
| | - M Pfeiffer
- Klinik für Augenheilkunde, Universitätsklinikum des Saarlandes (UKS), Homburg/Saar, Deutschland
| | - U Reinert
- Klinik für Augenheilkunde, Universitätsklinikum des Saarlandes (UKS), Homburg/Saar, Deutschland
| | - H Sideroudi
- Klinik für Augenheilkunde, Universitätsklinikum des Saarlandes (UKS), Homburg/Saar, Deutschland
| | - B Seitz
- Klinik für Augenheilkunde, Universitätsklinikum des Saarlandes (UKS), Homburg/Saar, Deutschland
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Hamon L, Schlötzer-Schrehardt U, Flockerzi FA, Seitz B, Daas L. Morphological characterization and clinical effects of stromal alterations after intracorneal ring segment implantation in keratoconus. Graefes Arch Clin Exp Ophthalmol 2022; 260:2299-2308. [PMID: 35106630 PMCID: PMC9203383 DOI: 10.1007/s00417-022-05572-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 01/16/2022] [Accepted: 01/20/2022] [Indexed: 01/15/2023] Open
Abstract
PURPOSE To analyze the histological and (ultra)structural stromal tissue changes after femtosecond (Fs) laser-assisted intracorneal ring segment (ICRS) implantation and their refractive and topographic effects in patients with keratoconus. METHODS This monocentric retrospective case series included 15 consecutive patients with clinical peri-segmental lamellar channel deposits after treatment with Fs-ICRS implantation for keratoconus. The stromal changes were investigated using in vivo confocal microscopy. Two patients underwent a penetrating keratoplasty after the Fs-ICRS implantation; the explanted corneas were processed for histopathology and transmission electron microscopy (TEM). Refractive and topographic effects were investigated comparing the uncorrected (UDVA) and corrected (CDVA) distance visual acuity, spherical equivalent (SE), flat (K1), steep (K2), and steepest (Kmax) keratometry before and after detection of lamellar channel deposits. RESULTS In vivo confocal microscopy revealed diffuse linear and focal granular hyperreflective structures. Histologically, there was mild proliferation of fibroblasts and fibrosis. TEM demonstrated focal accumulations of degenerated keratocytes with cytoplasmic lipid inclusions. There were no significant changes for UDVA (Δ = 0.0 ± 0.2 logMAR; p = 0.67), CDVA (Δ = 0.0 ± 0.1 logMAR; p = 0.32), SE (Δ 0.1 ± 0.9 D; p = 0.22), K1 (Δ = 0.3 ± 1.0 D; p = 0.28), K2 (Δ = 0.1 ± 0.9 D; p = 0.51), and Kmax (Δ = 0.3 ± 1.5 D; p = 0.17). CONCLUSIONS Two types of structural stromal changes were identified: (1) diffuse peri-segmental fibrosis and (2) lamellar channel deposits. These structural changes showed no evidence of a relevant refractive or topographic effect.
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Affiliation(s)
- Loïc Hamon
- Department of Ophthalmology, Saarland University Medical Center (UKS), Kirrberger Straße 100, Bld. 22, 66421 Homburg, Saar Germany
| | - Ursula Schlötzer-Schrehardt
- Department of Ophthalmology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Fidelis A. Flockerzi
- Department of Pathology, Saarland University Medical Center (UKS), Homburg, Saar Germany
| | - Berthold Seitz
- Department of Ophthalmology, Saarland University Medical Center (UKS), Kirrberger Straße 100, Bld. 22, 66421 Homburg, Saar Germany
| | - Loay Daas
- Department of Ophthalmology, Saarland University Medical Center (UKS), Kirrberger Straße 100, Bld. 22, 66421 Homburg, Saar Germany
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Deshmukh R, Nair S, Vaddavalli PK, Agrawal T, Rapuano CJ, Beltz J, Vajpayee RB. Post-penetrating keratoplasty astigmatism. Surv Ophthalmol 2021; 67:1200-1228. [PMID: 34808143 DOI: 10.1016/j.survophthal.2021.11.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 11/06/2021] [Accepted: 11/15/2021] [Indexed: 10/19/2022]
Abstract
Postoperative astigmatism is one of the common complications affecting visual outcomes after a penetrating keratoplasty. It can result from various factors related to host, donor and surgical technique, resulting in suboptimal visual outcome. While some of the measures taken during preoperative planning and during actual surgery can reduce the magnitude of postoperative astigmatism, postoperative correction of astigmatism is often required in cases with high degrees of astigmatism. When spectacles and contact lenses fail to provide optimal visual outcomes, various surgical techniques that include astigmatic keratotomy, compression sutures, toric intraocular lens placement, and laser refractive procedures can be considered. When none of these techniques are able to achieve a desired result with in the acceptable optical range, a repeat keratoplasty is considered a last option. We discuss the various causes and management of complication of postoperative astigmatism occurring after a full thickness corneal transplantation surgery.
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Affiliation(s)
| | - Sridevi Nair
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | | | - Tushar Agrawal
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | | | | | - Rasik B Vajpayee
- Royal Victorian Eye and Ear Hospital, Melbourne, Australia; Vision Eye Institute, Melbourne, Australia; University of Melbourne, Australia
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Deshmukh R, Stevenson LJ, Vajpayee RB. Laser-assisted corneal transplantation surgery. Surv Ophthalmol 2021; 66:826-837. [PMID: 33524460 DOI: 10.1016/j.survophthal.2021.01.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 01/15/2021] [Accepted: 01/18/2021] [Indexed: 12/01/2022]
Abstract
Corneal transplant surgeries have a broad range of indications with outcomes largely dependent on surgeon experience. Traditional manual techniques have certain limitations pertaining to the preparation of donor tissue and the recipient bed that might affect the predictability of visual outcomes. Use of lasers for keratoplasty procedures not only improves the repeatability and consistency of the technique, but also enables the surgeon to control the thickness and shape of the transplant tissue tailored to the specific condition. Despite the advantages, cost-effectiveness and technical know-how remain the major challenges. We discuss the various techniques of laser-assisted keratoplasties with respect to their methods, precision, and efficacy in various corneal indications.
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Affiliation(s)
- Rashmi Deshmukh
- Division of Ophthalmology and Visual Sciences, Eye ENT Centre, Queens Medical Centre, University of Nottingham, UK.
| | | | - Rasik B Vajpayee
- Royal Victorian Eye and Ear Hospital, Melbourne, Australia; Vision Eye Institute, Melbourne, Australia; University of Melbourne, Australia
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Sahay P, Stevenson LJ, Agarwal T, Sharma B, Sharma N, Vajpayee RB. Shaped corneal transplantation surgery. Br J Ophthalmol 2020; 105:9-16. [PMID: 32217546 DOI: 10.1136/bjophthalmol-2019-315754] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 02/22/2020] [Accepted: 03/11/2020] [Indexed: 11/04/2022]
Abstract
Since its inception in 1905, keratoplasty techniques have continuously evolved. Shaped keratoplasty procedures have allowed corneal surgeons to use complex graft-host junctions and non-circular graft designs to optimise wound strength and healing, facilitate early suture removal and expedite visual rehabilitation. While this was initially limited to penetrating procedures, shaped lamellar keratoplasty techniques have since emerged. Furthermore, the arrival of femtosecond laser has dramatically increased the range of graft designs available to surgeons, due to the technology's ability to precisely cut complex wound edges. This review describes the broad range of shaped keratoplasty grafts currently available and elaborates on their respective advantages and disadvantages in relation to conventional keratoplasty.
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Affiliation(s)
- Pranita Sahay
- Dr. R. P. Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | | | - Tushar Agarwal
- Dr. R. P. Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Bhavana Sharma
- Department of Ophthalmology, All India Institute of Medical Sciences, Bhopal, India
| | - Namrata Sharma
- Dr. R. P. Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Rasik B Vajpayee
- Royal Victorian Eye and Ear Hospital, East Melbourne, Victoria, Australia .,University of Melbourne, Parkville, Victoria, Australia.,Vision Eye Institute, Melbourne, Victoria, Australia
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Boden KT, Schlosser R, Boden K, Januschowski K, Szurman P, Rickmann A. Novel Liquid Interface for Femtosecond Laser-Assisted Penetrating Keratoplasty. Curr Eye Res 2020; 45:1051-1057. [DOI: 10.1080/02713683.2020.1716985] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
| | | | - Katrin Boden
- Eye Clinic Sulzbach, Knappschaft Hospital Saar, Sulzbach, Germany
| | - Kai Januschowski
- Eye Clinic Sulzbach, Knappschaft Hospital Saar, Sulzbach, Germany
- Centre for Ophthalmology, University Eye Hospital Tuebingen, Tuebingen, Germany
| | - Peter Szurman
- Eye Clinic Sulzbach, Knappschaft Hospital Saar, Sulzbach, Germany
- Centre for Ophthalmology, University Eye Hospital Tuebingen, Tuebingen, Germany
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Tóth G, Szentmáry N, Langenbucher A, Akhmedova E, El-Husseiny M, Seitz B. Comparison of Excimer Laser Versus Femtosecond Laser Assisted Trephination in Penetrating Keratoplasty: A Retrospective Study. Adv Ther 2019; 36:3471-3482. [PMID: 31650512 DOI: 10.1007/s12325-019-01120-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Indexed: 11/30/2022]
Abstract
INTRODUCTION To compare the impact of non-mechanical excimer-assisted (EXCIMER) and femtosecond laser-assisted (FEMTO) trephination on outcomes after penetrating keratoplasty (PK). METHODS In this retrospective study, 68 eyes from 23 females and 45 males (mean age at time of surgery, 53.3 ± 19.8 years) were included. Inclusion criteria were one surgeon (BS), primary central PK, Fuchs' dystrophy (FUCHS) or keratoconus (KC), no previous intraocular surgery, graft oversize 0.1 mm and 16-bite double running suture. Trephination was performed using a manually guided 193-nm Zeiss Meditec MEL70 excimer laser (EXCIMER group: 18 FUCHS, 17 KC) or 60-kHz IntraLase™ femtosecond laser (FEMTO group: 16 FUCHS, 17 KC). Subjective refractometry (trial glasses) and corneal topography analysis (Pentacam HR; Casia SS-1000 AS-OCT; TMS-5) were performed preoperatively, before removal of the first suture (11.4 ± 1.9 months) and after removal of the second suture (22.6 ± 3.8 months). RESULTS Before suture removal, mean refractive/AS-OCT topographic astigmatism did not differ significantly between EXCIMER and FEMTO. After suture removal, mean refractive/Pentacam/AS-OCT topographic astigmatism was significantly higher in the FEMTO (6.2 ± 2.9 D/7.1 ± 3.2 D/7.4 ± 3.3 D) than in the EXCIMER patients (4.3 ± 3.0 D/4.4 ± 3.1 D/4.0 ± 2.9 D) (p ≤ 0.005). Mean corrected distance visual acuity increased from 0.22 and 0.23 preoperatively to 0.55 and 0.53 before or 0.7 and 0.6 after suture removal in the EXCIMER and FEMTO groups, respectively. Differences between EXCIMER and FEMTO were only pronounced in the KC subgroup. CONCLUSION Non-mechanical EXCIMER trephination seems to have advantages regarding postoperative corneal astigmatism and visual acuity compared with FEMTO trephination, especially in KC. A bigger sample size and longer follow-up are needed to evaluate the long-term impact of EXCIMER and FEMTO trephination on postoperative topographic and visual outcomes.
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Affiliation(s)
- Gábor Tóth
- Department of Ophthalmology, Saarland University Medical Center, Kirrberger Str. 100, 66424, Homburg/Saar, Germany.
- Department of Ophthalmology, Semmelweis University, Mária utca 39, 1085, Budapest, Hungary.
| | - Nóra Szentmáry
- Department of Ophthalmology, Saarland University Medical Center, Kirrberger Str. 100, 66424, Homburg/Saar, Germany
- Department of Ophthalmology, Semmelweis University, Mária utca 39, 1085, Budapest, Hungary
| | - Achim Langenbucher
- Experimental Ophthalmology, Saarland University, Kirrberger Str. 100, 66424, Homburg/Saar, Germany
| | - Elina Akhmedova
- Department of Ophthalmology, Saarland University Medical Center, Kirrberger Str. 100, 66424, Homburg/Saar, Germany
| | - Moatasem El-Husseiny
- Department of Ophthalmology, Saarland University Medical Center, Kirrberger Str. 100, 66424, Homburg/Saar, Germany
| | - Berthold Seitz
- Department of Ophthalmology, Saarland University Medical Center, Kirrberger Str. 100, 66424, Homburg/Saar, Germany
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Endothelial cell density and corneal graft thickness following excimer laser vs. femtosecond laser-assisted penetrating keratoplasty—a prospective randomized study. Graefes Arch Clin Exp Ophthalmol 2019; 257:975-981. [DOI: 10.1007/s00417-019-04263-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 01/31/2019] [Accepted: 02/09/2019] [Indexed: 10/27/2022] Open
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Seitz B, Langenbucher A, Hager T, Janunts E, El-Husseiny M, Szentmáry N. Penetrating Keratoplasty for Keratoconus - Excimer Versus Femtosecond Laser Trephination. Open Ophthalmol J 2017; 11:225-240. [PMID: 28932339 PMCID: PMC5585536 DOI: 10.2174/1874364101711010225] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 04/29/2017] [Accepted: 06/13/2017] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND In case of keratoconus, rigid gas-permeable contact lenses as the correction method of first choice allow for a good visual acuity for quite some time. In a severe stage of the disease with major cone-shaped protrusion of the cornea, even specially designed keratoconus contact lenses are no more tolerated. In case of existing contraindications for intrastromal ring segments, corneal transplantation typically has a very good prognosis. METHODS In case of advanced keratoconus - especially after corneal hydrops due to rupture of Descemet's membrane - penetrating keratoplasty (PKP) still is the surgical method of first choice. Noncontact excimer laser trephination seems to be especially beneficial for eyes with iatrogenic keratectasia after LASIK and those with repeat grafts in case of "keratoconus recurrences" due to small grafts with thin host cornea. For donor trephination from the epithelial side, an artificial chamber is used. Wound closure is achieved with a double running cross-stitch suture according to Hoffmann. Graft size is adapted individually depending on corneal size ("as large as possible - as small as necessary"). Limbal centration will be preferred intraoperatively due to optical displacement of the pupil. During the last 10 years femtosecond laser trephination has been introduced from the USA as a potentially advantageous approach. RESULTS Prospective clinical studies have shown that the technique of non-contact excimer laser PKP improves donor and recipient centration, reduces "vertical tilt" and "horizontal torsion" of the graft in the recipient bed, thus resulting in significantly less "all-sutures-out" keratometric astigmatism (2.8 vs. 5.7 D), higher regularity of the topography (SRI 0.80 vs. 0.98) and better visual acuity (0.80 vs. 0.63) in contrast to the motor trephine. The stage of the disease does not influence functional outcome after excimer laser PKP. Refractive outcomes of femtosecond laser keratoplasty, however, resemble that of the motor trephine. CONCLUSIONS In contrast to the undisputed clinical advantages of excimer laser keratoplasty with orientation teeth/notches in keratoconus, the major disadvantage of femtosecond laser application is still the necessity of suction and applanation of the cone during trephination with intraoperative pitfalls and high postoperative astigmatism.
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Affiliation(s)
- Berthold Seitz
- Department of Ophthalmology, Saarland University Medical Center UKS, Homburg/Saar, Germany
| | - Achim Langenbucher
- Institute of Experimental Ophthalmology, University of Saarland, Homburg/Saar, Germany
| | - Tobias Hager
- Department of Ophthalmology, Saarland University Medical Center UKS, Homburg/Saar, Germany
| | - Edgar Janunts
- Institute of Experimental Ophthalmology, University of Saarland, Homburg/Saar, Germany
| | - Moatasem El-Husseiny
- Department of Ophthalmology, Saarland University Medical Center UKS, Homburg/Saar, Germany
| | - Nora Szentmáry
- Department of Ophthalmology, Saarland University Medical Center UKS, Homburg/Saar, Germany
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Resch MD, Zemova E, Marsovszky L, Szentmáry N, Bauer F, Daas L, Pattmöller M, El-Husseiny M, Németh J, Nagy ZZ, Seitz B. In Vivo Confocal Microscopic Imaging of the Cornea After Femtosecond and Excimer Laser-assisted Penetrating Keratoplasty. J Refract Surg 2016; 31:620-6. [PMID: 26352568 DOI: 10.3928/1081597x-20150820-08] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 07/16/2015] [Indexed: 11/20/2022]
Abstract
PURPOSE To examine the microstructure of the cornea after excimer and femtosecond laser-assisted penetrating keratoplasty (ELAK and FLAK) in eyes with Fuchs' dystrophy and keratoconus. METHODS Fifty-seven patients were divided into four groups according to corneal disease and surgical technique: Fuchs' dystrophy and ELAK (n = 9; mean age: 70.4 ± 10.6 years); Fuchs' dystrophy and FLAK (n = 13; mean age: 64.3 ± 11.2 years); keratoconus and ELAK (n = 9; mean age: 47.4 ± 13.9 years); and keratoconus and FLAK (n = 9; mean age: 43.5 ± 13.8 years). The control group comprised individuals without ocular disease (n = 17; mean age: 39.9 ± 17.3 years). In vivo investigation of the corneal graft and graft-host junction zone was performed with confocal corneal microscopy. RESULTS All corneal grafts were transparent and no rejection reaction could be observed during the follow-up period. Confocal microscopy revealed no difference in basal epithelial cell density compared to controls. Anterior keratocyte density was lower than in the control group (818 ± 131 cells/mm(2)) in all four treatment groups (596 ± 174, 586 ± 113, 529 ± 75, 552 ± 91 cells/mm(2)). Langerhans cells could barely be seen; there was no difference in the cutting edge configuration and wound integrity. CONCLUSIONS In vivo confocal microscopy provided evidence that good alignment of graft-host junction could be created with both techniques. The excimer laser was not inferior to the femtosecond laser in performing corneal cuts. The low density of Langerhans cells revealed well-controlled cellular immunological response and sustained corneal integrity in both laser groups.
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11
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Comparison of Long-Term Outcomes of Femtosecond Laser-Assisted Keratoplasty with Conventional Keratoplasty. Cornea 2016; 35:293-8. [DOI: 10.1097/ico.0000000000000739] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Excimer versus Femtosecond Laser Assisted Penetrating Keratoplasty in Keratoconus and Fuchs Dystrophy: Intraoperative Pitfalls. J Ophthalmol 2015; 2015:645830. [PMID: 26483974 PMCID: PMC4592921 DOI: 10.1155/2015/645830] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2015] [Revised: 05/02/2015] [Accepted: 05/13/2015] [Indexed: 11/18/2022] Open
Abstract
Purpose. To assess the intraoperative results comparing two non-mechanical laser assisted penetrating keratoplasty approaches in keratoconus and Fuchs dystrophy. Patients and Methods. 68 patients (age 18 to 87 years) with keratoconus or Fuchs dystrophy were randomly distributed to 4 groups. 35 eyes with keratoconus and 33 eyes with Fuchs dystrophy were treated with either excimer laser ([Exc] groups I and II) or femtosecond laser-assisted ([FLAK] groups III and IV) penetrating keratoplasty. Main intraoperative outcome measures included intraoperative decentration, need for additional interrupted sutures, alignment of orientation markers, and intraocular positive pressure (vis a tergo). Results. Intraoperative recipient decentration occurred in 4 eyes of groups III/IV but in none of groups I/II. Additional interrupted sutures were not necessary in groups I/II but in 5 eyes of groups III/IV. Orientation markers were all aligned in groups I/II but were partly misaligned in 8 eyes of groups III/IV. Intraocular positive pressure grade was recognized in 12 eyes of groups I/II and in 19 eyes of groups III/IV. In particular, in group III, severe vis a tergo occurred in 8 eyes. Conclusions. Intraoperative decentration, misalignment of the donor in the recipient bed, and need for additional interrupted sutures as well as high percentage of severe intraocular positive pressure were predominantly present in the femtosecond laser in keratoconus eyes.
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Linke SJ, Ren L, Frings A, Steinberg J, Wöllmer W, Katz T, Reimer R, Hansen NO, Jowett N, Richard G, Dwayne Miller RJ. [Perspectives of laser-assisted keratoplasty: current overview and first preliminary results with the picosecond infrared laser (λ = 3 µm)]. Ophthalmologe 2015; 111:523-30. [PMID: 24942118 DOI: 10.1007/s00347-013-2995-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND This article provides a review of the current state of laser-assisted keratoplasty and describes a first proof of concept study to test the feasibility of a new mid-infrared (MIR) picosecond laser to perform applanation-free corneal trephination. METHODS The procedure is based on a specially adapted laser system (PIRL-HP2-1064 OPA-3000, Attodyne, Canada) which works with a wavelength of 3,000 ± 90 nm, a pulse duration of 300 ps and a repetition rate of 1 kHz. The picosecond infrared laser (PIRL) beam is delivered to the sample by a custom-made optics system with an implemented scanning mechanism. Corneal specimens were mounted on an artificial anterior chamber and subsequent trephination was performed with the PIRL under stable intraocular pressure conditions. RESULTS A defined corneal ablation pattern, e.g. circular, linear, rectangular or disc-shaped, can be selected and its specific dimensions are defined by the user. Circular and linear ablation patterns were employed for the incisions in this study. Linear and circular penetrating PIRL incisions were examined by macroscopic inspection, histology, confocal microscopy and environmental scanning electron microscopy (ESEM) for characterization of the incisional quality. Using PIRL reproducible and stable incisions could be made in human and porcine corneal samples with minimal damage to the surrounding tissue. CONCLUSION The PIRL laser radiation in the mid-infrared spectrum with a wavelength of 3 µm is exactly tuned to one of the dominant vibrational excitation bands of the water molecule, serves as an effective tool for applanation-free corneal incision and might broaden the armamentarium of corneal transplant surgery.
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Affiliation(s)
- S J Linke
- Klinik und Poliklinik für Augenheilkunde, Universitätsklinikum Eppendorf (UKE), Martinistr. 52, 20246, Hamburg, Deutschland,
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A new technology for applanation free corneal trephination: the picosecond infrared laser (PIRL). PLoS One 2015; 10:e0120944. [PMID: 25781907 PMCID: PMC4363595 DOI: 10.1371/journal.pone.0120944] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Accepted: 01/29/2015] [Indexed: 11/19/2022] Open
Abstract
The impact of using a Femtosecond laser on final functional results of penetrating keratoplasty is low. The corneal incisions presented here result from laser ablations with ultrafast desorption by impulsive vibrational excitation (DIVE). The results of the current study are based on the first proof-of-principle experiments using a mobile, newly introduced picosecond infrared laser system, and indicate that wavelengths in the mid-infrared range centered at 3 μm are efficient for obtaining applanation-free deep cuts on porcine corneas.
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Abstract
BACKGROUND In cases of contact lens intolerance and/or central corneal scars, corneal transplantation is indicated for advanced keratoconus. This can be performed as deep anterior lamellar keratoplasty (DALK) or as penetrating keratoplasty (PKP). The German keratoplasty registry shows that the proportion of anterior lamellar grafts in Germany has remained stable at approximately 5 % in recent years. METHODS Up to now DALK has not been technically standardized but can result in a good visual acuity using the big bubble technique if Descemet's membrane is laid bare intraoperatively. In 10-20 % a conversion to PKP is required if perforation of Descemet's membrane occurs. In cases of advanced keratoconus PKP is still the method of first choice especially after corneal hydrops due to rupture of Descemet's membrane. Non-contact excimer laser trephination seems to be especially beneficial for eyes with iatrogenic keratectasia after LASIK and those with repeat grafts in cases of keratoconus recurrence due to the graft being too small. For donor trephination from the epithelial side, an artificial chamber is used. Wound closure is achieved by a double running cross-stitch suture according to Hoffmann. Graft size is adapted individually depending on corneal size (as large as possible and as small as necessary). Limbal centration is given priority intraoperatively due to optical displacement of the pupil. RESULTS Prospective clinical studies have shown that the technique of non-contact excimer laser PKP improves donor and recipient centration, reduces vertical tilt and horizontal torsion of the graft in the recipient bed, thus resulting in significantly less all-sutures-out keratometric astigmatism (2.8 D versus 5.7 D), higher regularity of the topography (SRI 0.80 vs. 0.98) and better visual acuity (0.80 vs. 0.63) in contrast to the motor trephine. The stage of the disease does not influence functional outcome after excimer laser PKP. CONCLUSIONS In cases with optimal course DALK achieves the same visual outcome as mechanical PKP but the healthy endothelium can be preserved and endothelial immune reactions are prevented in keratoconus. In contrast to the undisputed clinical advantages of excimer laser keratoplasty with orientation teeth/notches in keratoconus, the major disadvantage of femtosecond laser application is still the necessity of suction and applanation of the cone during trephination.
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Gatzioufas Z, Labiris G, Mauer B, Zemova E, Eppig T, Langenbucher A, Seitz B. Elevated intraocular pressure in the early postoperative period following excimer laser penetrating keratoplasty for keratoconus. Ophthalmic Surg Lasers Imaging Retina 2013; 43:467-71. [PMID: 23356820 DOI: 10.3928/15428877-20121002-01] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2012] [Accepted: 08/08/2012] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND OBJECTIVE To assess the incidence of elevated intraocular pressure (IOP) in the early postoperative period after excimer laser penetrating keratoplasty for keratoconus and reveal potential associations with anterior segment parameters. PATIENTS AND METHODS This prospective, interventional study consisted of 40 patients with keratoconus who were treated with excimer laser penetrating keratoplasty. Corneal pachymetry, anterior chamber depth, anterior chamber volume, and anterior segment angle were measured by Scheimpflug camera preoperatively and 2 months postoperatively. IOP was obtained using Goldmann applanation tonometry. Student's t tests and Pearson correlation were applied. A P value of .05 or less was considered significant. RESULTS IOP increased from 16.3 ± 3.5 preoperatively to 19.3 ± 5.2 mm Hg postoperatively (P = .007). Significant differences were detected in corneal pachymetry (P < .008), anterior chamber depth (P < .001), and anterior chamber volume (P = .03). Postoperative IOP was significantly correlated with anterior segment angle, anterior chamber depth, and corneal pachymetry. CONCLUSION Elevated IOP in the early postoperative period after excimer laser penetrating keratoplasty is significantly correlated with changes in the anterior chamber architecture.
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Affiliation(s)
- Zisis Gatzioufas
- Department of Ophthalmology, University Medical Center of Saarland UKS, Saar, Germany.
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Ninios K, Matoula P, Szentmary N, Schirra F, Seitz B. Results of excimer laser penetrating keratoplasty in aphakic eyes. Graefes Arch Clin Exp Ophthalmol 2012; 251:1185-9. [PMID: 23129005 DOI: 10.1007/s00417-012-2187-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2012] [Revised: 10/12/2012] [Accepted: 10/15/2012] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Corneal grafting in aphakic eyes is often challenging. We report about the outcome of excimer laser trephination in aphakic eyes. METHODS We examined 17 eyes of 17 patients. Diagnosis in 11 eyes was endothelial decompensation and in six, corneal scars. We performed an excimer laser keratoplasty with intraoperative "Flieringa ring" suturing. Follow-up ranged between 3 and 41 (17.6 ± 11.7) months. Main outcome measures included: best-corrected visual acuity (BCVA), intraocular pressure (IOP), topographic astigmatism, corneal refractive power (CRP), central corneal thickness (CCT) and endothelial cell density (ECD). RESULTS Preoperative BCVA was light perception in two eyes, hand motion in seven, finger counting in one eye, under 20/400 in six eyes and 20/200 in one eye. IOP ranged between 4 and 28 (13.6 ± 5.1) mmHg. Topographic astigmatism ranged from 0.5 to 18.5 (7.0 ± 6.9) dioptres. CRP was between 38 and 59 (46 ± 9) dioptres. CCT was between 404 and 1069 (748 ± 181) μm. Postoperative BCVA was hand motion in five eyes, under 20/400 in two and ranged between 20/200 and 20/20 in ten eyes. IOP ranged between 10 and 40 (18.3 ± 8.5) mmHg. Topographic astigmatism ranged from 0.9 to 13 (5.5 ± 3.2) dioptres. CRP was between 31.9 and 46.7 (42 ± 4.1) dioptres. CCT was between 349 and 820 (552 ± 115.57) μm. ECD was between 592 and 2319 (1674 ± 553) cells/mm(2). CONCLUSIONS Excimer laser trephination can deliver beneficial visual outcomes in most of the aphakic eyes.
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Affiliation(s)
- K Ninios
- Department of Ophthalmology, University Medical Center of Saarland, Kirrbergerstr. 22, Saarland 66421, Germany.
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