Unilateral Granular Type 2 Corneal Dystrophy With Exacerbation After LASIK

PURPOSE

The aim of this study was to report a case of unilateral granular corneal dystrophy type 2 (GCD2) with exacerbation after bilateral laser in situ keratomileusis (LASIK).

METHODS

Clinical evaluation, Scheimpflug imaging, anterior segment optical coherence tomography (AS-OCT), cytology, and genetic testing were used to confirm the diagnosis of unilateral GCD2 with exacerbation after bilateral LASIK. Detailed literature review for possible unilateral GCD2 presentations was performed.

RESULTS

A 54-year-old White woman presented with blurred vision in her left eye and a history of bilateral LASIK performed 8 years before. Examination revealed dense opacities in the left cornea only, which were confirmed to be confined to the LASIK interface and adjacent corneal stromal tissue, as determined by AS-OCT. The patient underwent flap lift, interface debris removal, and stromal bed phototherapeutic keratectomy. Cytological analysis showed eosinophilic corneal stromal deposits that stained with trichrome stain and were congophilic on Congo red stain. Genetic testing was positive for heterozygous GCD2 transforming growth factor β-induced gene ( TGFBI ), c.371G>A, p.R124H mutation. There were no opacities identifiable in the right eye on serial slit-lamp examination, Scheimpflug imaging, or OCT imaging at 4 or 8 years after bilateral LASIK. Literature review failed to identify any previous reports of unilateral GCD2.

CONCLUSIONS

This is the first known reported case of unilateral granular corneal dystrophy type 2. LASIK is contraindicated in eyes with corneal stromal dystrophies related to mutations in TGFBI as both flap creation and laser ablation can exacerbate visually significant opacity formation. Scheimpflug and AS-OCT imaging are useful to identify opacities in GCD2.

Novel Manifestation of Corneal Dystrophy After Keratorefractive Surgery

PURPOSE

This study aimed to report cases of bilateral corneal Bowman layer deposits in 4 patients with a history of keratorefractive surgery. To our knowledge, this condition has not previously been reported and should be distinguished from granular corneal dystrophy type 2 and other corneal dystrophies.

METHODS

We reviewed all available medical records that were collected between January 2010 and December 2021 at a tertiary referral center and performed whole-exome sequencing to provide diagnostic information.

RESULTS

Four patients exhibited similar bilateral corneal deposits that were observed more than 10 years after keratorefractive surgery. The patients' ages ranged from 36 to 53 years; 3 of the 4 patients were female. Three patients received laser in situ keratomileusis surgery, and 1 received radial keratotomy. All 4 patients denied having a family history of ocular diseases and reported an uneventful postoperative course. On examination, the best-corrected visual acuity ranged from 6/10 to 6/6 in all 4 patients. Slit-lamp examination revealed bilateral superficial corneal deposits involving the central cornea, and anterior segment optical coherence tomography revealed hyperreflective deposits located in the Bowman layer. Such unique manifestations suggested corneal dystrophy; thus, whole-exome sequencing was performed on all 4 patients. Only 1 patient exhibited a missense mutation in TGFBI . We further analyzed common de novo mutations to explore possible candidate genes associated with this presentation.

CONCLUSIONS

We report a rare entity of presumed corneal dystrophy with deposits located in the Bowman layer in 4 patients who had received keratorefractive surgery. Clarifying the underlying pathophysiology and genetic predisposition of this disease may aid in diagnosing and preventing potential complications after keratorefractive surgery.

Indocyanine green-assisted goniotomy in eyes with hazy cornea

Corneal haze, due to edema or opacity, is a major contraindication for performing ab interno angle surgeries such as goniotomy in children with primary congenital glaucoma (PCG), despite otherwise favorable surgical outcomes expected in these patients. In this case series involving patients of PCG with moderate corneal haze, the authors describe a technique for performing goniotomy in cases with compromised visibility by using indocyanine green (ICG) to aid in the visualization of angle structures. The authors used 0.2% ICG intracamerally, which stained the anterior and posterior trabecular meshwork (TM) with different intensities, before proceeding with goniotomy. The junction between the two zones was discernible due to the contrast imparted by ICG staining, despite poor visibility, allowing the surgeon to incise the TM at the correct site. The possibility of performing goniotomy in such patients with the help of ICG can revolutionize our surgical approach to patients with PCG and corneal edema.

Variable Phenotype of Congenital Corneal Opacities in Biallelic CYP1B1 Pathogenic Variants

PURPOSE

The aim of this study is to describe the variable phenotype of congenital corneal opacities occurring in patients with biallelic CYP1B1 pathogenic variants.

METHODS

A retrospective chart review was conducted to identify patients with congenital corneal opacities and CYP1B1 pathogenic variants seen at UPMC Children's Hospital of Pittsburgh. Ophthalmic examination, high-frequency ultrasound, anterior segment optical coherence tomography, histopathologic images, and details of genetic testing were reviewed.

RESULTS

Three children were identified. All presented with raised intraocular pressure. Two patients showed bilateral limbus-to-limbus avascular corneal opacification that did not resolve with intraocular pressure control; 1 showed unilateral avascular corneal opacity with a crescent of clear cornea, iridocorneal adhesions, iridolenticular adhesions, and classical features of congenital glaucoma in the fellow eye (enlarged corneal diameter, Haab striae, and clearing of the corneal clouding with appropriate intraocular pressure control). The first 2 patients were visually rehabilitated with penetrating keratoplasty. Histopathology revealed distinct features: a variably keratinized epithelium; a thick but discontinuous Bowman-like layer with areas of disruption and abnormal cellularity; Descemet membrane, when observed, showed reduced endothelial cells; and no pathological changes of Haab striae were identified. Two patients had compound heterozygous pathogenic variants in CYP1B1 causing premature stop codons, whereas 1 was homozygous for a pathogenic missense variant.

CONCLUSIONS

Congenital corneal opacities seen in biallelic CYP1B1 pathogenic variants have a variable phenotype. One is that commonly termed as Peters anomaly type 1 (with iridocorneal adhesions, with or without iridolenticular adhesions) and the other is a limbus-to-limbus opacity, termed CYP1B1 cytopathy. Clinicians should be aware of this phenotypic variability.

Excimer Laser Phototherapeutic Keratectomy for Anterior Corneal Opacification After Descemet Membrane Endothelial Keratoplasty

PURPOSE

The aim of this study was to assess the long-term outcome of excimer laser phototherapeutic keratectomy (PTK) for treating remaining anterior corneal opacities after Descemet membrane endothelial keratoplasty (DMEK).

METHODS

This cohort study analyzed 67 eyes of 66 patients undergoing PTK in addition to and after DMEK between 2012 and 2021 at the Department of Ophthalmology, University of Cologne. Patients who were treated by PTK after previous DMEK on the same eye were included. The outcome parameters were best corrected visual acuity (BCVA), changes in refraction, endothelial cell density, corneal densitometry, central corneal thickness, and total corneal higher order aberrations. Patients with visual limitations in addition to anterior opacification were analyzed separately for their visual outcome. Eyes with severe visual limitations that have a very limited visual potential were excluded from the study. In addition, patients with not at least 1 postoperative follow-up examination were excluded from the study.

RESULTS

In this study, 67 eyes of 66 patients met all inclusion criteria. The median follow-up period was 13.1 (quartiles: 4.1; 30.7; interquartile range 26.6) months. The mean (±SD) BCVA improved from (logarithm of the minimum angle of resolution) 0.54 (±0.32) to 0.38 (±0.27) at the first postoperative visit ( P < 0.001) and remained significantly improved at all follow-up examinations compared with preoperative BCVA. Refraction and endothelial cell density did not change significantly after PTK. There was a significant decrease in corneal backscatter in the anterior corneal layer ( P < 0.001), and the total higher order aberration ( P = 0.02) and central corneal thickness were significantly reduced at the most recent postoperative visit ( P < 0.001). No immune reactions were observed.

CONCLUSIONS

Excimer laser PTK after DMEK for persisting anterior corneal opacities has the potential to significantly improve patients' vision without affecting refractive parameters or endothelial cell density.

Aesthetic corneal tattooing/keratopigmentation using tattoo pen machine: choosing suitable method and color

PURPOSE

This article aims to present the corneal tattooing method and how using a tattoo pen machine can improve aesthetic appearance in patients with corneal leukoma.

METHODS

In this study, 42 patients were evaluated who had no visual potential and who had undergone colored corneal tattooing using an automatic tattoo pen machine for aesthetic purposes. The procedure was conducted according to the principles of the Declaration of Helsinki. The commercially available tattoo ink that has traditionally been used on human skin (brown, green, and black) for years was used for all the patients in this study, and 252 corneal photographs (with a Topcon slit lamp imaging device at 16 magnifications, i.e., 16 ×) taken within the last 2 years were evaluated retrospectively. Red, green, and blue (RGB) and hue, saturation, and lightness (HSL) values of the tattooed areas, such as pupils and iris, in corneal photographs were determined online using the Color Code Finder program. The RGB and HSL values of the pupil and iris were compared before surgery on the first day and first week, first month, third month, and twelfth month after surgery.

RESULTS

In the first postoperative month, the mean pupil lightness (L) and iris L values were found to have increased by 10.7% and 5.7%, respectively. Between the first month and the first year, the L value of the mean pupil and that of the iris increased by 1.7% and 5.2%, respectively. The increase in the RGB value of the mean pupil in the first month was statistically significant (p = 0.02). The highest increase in RGB values of the iris was observed in the first week and first month (p = 0.113). This result shows that the majority of fading occurred in the first month. After the first month, the increase in the L value in the black-colored pupil was less than that in the brown- or green-colored iris. These results show that light colors fade faster and more.

CONCLUSION

Esthetically, corneal leukoma causes severe psychological problems. Many patients are unable to use prosthetic contact lenses. Evisceration surgery has many complications, and limbal stem cells are used in evisceration surgery. Corneal tattooing using a tattoo pen machine is an easy, practical, and repeatable method used for aesthetic purposes. Successful results require the use of appropriate methods, ink, and ophthalmologist's experience. All patients in this study had a more aesthetic appearance than the preoperative white eye. Further studies are needed to develop a colored aesthetic tattooing method with a tattoo pen machine.

[PETERS ANOMALY AND PETERS PLUS SYNDROME]

INTRODUCTION

Peters anomaly is characterized by a defect in the development of the anterior segment of the eye during fetal development (Anterior segment dysgenesis). This anomaly presents a broad clinical presentation ranging from minimal peripheral corneal opacity to extensive adhesions of the iris and lens with dense central corneal opacity that impairs vision. Peters Plus Syndrome is a recessive autosomal syndrome manifested by Peters anomaly, along with systemic disorders such as brachydactyly (short fingers and toes), short stature, a developmental delay, dysmorphic facial features, and may accompanied with heart and genitourinary malformations. The most common sign of Peters' anomaly is corneal opacity that appears at birth. This opacity can cause blockage of the central visual axis and cause the development of a deprivational amblyopia. In addition, the patient may suffer from glaucoma due to malformations in the angle structures as well as a shallow anterior chamber. Treatments are aimed at clearing the central visual axis as soon as possible in order to allow the visual system to mature and to avoid the development of amblyopia. Full-thickness corneal transplantation combined with Cataract surgery if necessary is the current standard of care. Optical iridoplasty is a milder surgical alternative in cases where the corneal opacity is not significant.

[Analysis of long-term outcomes of penetrating keratoplasty for congenital corneal opacity]

Objective: To investigate the long-term outcomes of corneal grafts after penetrating keratoplasty(PK) for congenital corneal opacity(CCO) in children aged 0 to 5 years and the related influencing factors. Methods: It was a retrospective series case study. Data of 39 children (55 eyes) who underwent PK surgery due to CCO in the keratology Department of Beijing Tongren Hospital from April 2014 to April 2018 and were followed up for more than 30 months were collected. Among them, there were 17 males (43.6%) and 22 females (56.4%). The age at operation was (16.2±13.3) months, and the follow-up time was (46.4±13.8) months. Clinical data such as basic information, preoperative diagnosis, operation age, operation method and postoperative complications were recorded. The corneal graft transparency was analyzed according to preoperative diagnosis, corneal neovascularization area, age at surgery, monocular or binocular surgery interval, primary surgery type and further surgery, and postoperative complications were observed. Results: At 12 months, 24 months and the last follow-up after PK, 78.2% (43/55), 70.9% (39/55) and 58.2% (32/55) of the affected eyes had clear corneal grafts, respectively.There was no statistical significance between Peters anomaly and sclerocornea (P>0.05), while the extent of neovascularization in the limbus had a significant effect on corneal graft transparency, and graft opacity was more likely to occur in patients with vessel area exceeding 2 quadrants (P<0.05).The highest corneal graft transparency was found in children aged 1 to 3 years 80.8%(21/26) (P<0.05), followed by children younger than 6 months (7/15).The translucency rate of the corneal graft was higher in patients undergoing unilateral surgery than in those undergoing bilateral surgery (P<0.05).Translucency of corneal graft was higher in children with simple surgery than with combined surgery (P<0.05), however, cataract surgery after PK had no significant effect on corneal graft transparency (P>0.05).The postoperative complications mainly included immune rejection in 19 eyes (34.5%), complicated cataract in 13 eyes (23.6%), glaucoma in 7 eyes (13.2%), persistent corneal epithelial defect in 7 eyes (13.2%). Conclusions: After PK in children with CCO, the transparent rate of corneal grafts decreases gradually with time, but the long-term translucency of corneal grafts can still be obtained. The range of corneal neovascularization, age at the time of surgery, whether the surgery was binocular and whether the surgery was combined had an effect on the transparency of corneal graft.

Progeroid syndrome of De Barsy - a case report and review of ophthalmic literature

BACKGROUND

This report describes a very rare case of progeroid syndrome of De Barsy (Cutis laxa-corneal clouding syndrome).

MATERIALS AND METHODS

A 2 year-old child presented to the pediatric ophthalmology outpatients with bilateral congenital corneal opacification along with dysmorphic facial features, including loose wrinkled skin, progeroid appearance, delayed milestones, short stature, multiple hyper-extensible joints, muscular hypotonia, pectus excavatum and congenital dislocation of the hip joint. The child underwent a detailed ophthalmic work up and systemic evaluation by a clinical geneticist.

RESULTS

Ophthalmic management in the form of bilateral sequential penetrating keratoplasties and a left eye trabeculectomy for medically uncontrolled angle-closure glaucoma was performed. Visual rehabilitation with glasses and amblyopia therapy is ongoing. Histopathology of the corneal button revealed loss of the bowman's layer which was replaced by a fibrous pannus while the stroma showed loss of stromal lamellar architecture with anterior and mid stroma showing vascularization. Genetic testing confirmed a mutation in the PYCR1 gene for a homozygous autosomal recessive cutis laxa type IIB.

CONCLUSIONS

Although rare, De Barsy syndrome is an important cause of corneal opacification at birth with multiple systemic abnormalities that requires intervention.

Surgical Technique to Treat Presbyopic Inlay-Associated Corneal Haze With Sequential Excimer Photoablation: A Case Series

PURPOSE

To describe an approach using sequential excimer laser ablation of the stromal surface of the corneal flap with or without subsequent excimer ablation to the stromal bed to reduce presbyopic inlay-associated corneal haze.

METHODS

Twelve patients who underwent KAMRA inlay (Acufocus) explantation due to corneal haze were included. The mean interval between explantation and the primary surgery (phototherapeutic keratotomy [PTK] to corneal flap) was 16.2 ± 29.7 months (range = 1 to 83 months). The corneal flap was lifted and laid on an evisceration spoon and an excimer laser was used to ablate the flap stroma by 30 to 40 µm depth. Subsequently, an excimer laser was used to ablate and treat the stromal bed following a second flap lift according to the manifest refraction, leaving a minimal residual stromal bed thickness of greater than 300 µm. For both procedures, mitomycin C 0.02% was applied to the stromal bed before the flap was replaced and a bandage contact lens applied.

RESULTS

Reductions in corneal haze were observed, following PTK to the corneal flap with or without photorefractive keratectomy (PRK) to the stromal bed, both clinically and on imaging. No significant changes in uncorrected distance visual acuity (P = .442) and corrected distance visual acuity (P = .565) were observed. Improvements were observed for both spherical equivalent refractive errors (P = .036) and corneal light backscatter (P = .019). There were significant improvements in spherical aberrations (P = .014) but no changes in total lower and higher order aberrations.

CONCLUSIONS

PTK to the corneal flap with or without subsequent stromal bed PRK is an effective technique in treating corneal haze following presbyopic inlay explantation. [J Refract Surg. 2023;39(9):639-646.].

Intrastromal keratopigmentation: a boon for unsightly corneal scars

PURPOSE

The aim of this study was to improve cosmesis in patients with corneal opacity (CO) using newer organic micronized pigments.

METHODS

Settings: Tertiary Care eye center, Design: Retrospective study.

INCLUSION CRITERIA

Patients with unsightly corneal scars not suitable for keratoplasty, eccentric corneal opacity not requiring keratoplasty, or lenticular opacity/anterior or posterior capsular opacities in non-seeing eyes. Micronized organic pigment was used for keratopigmentation by the intrastromal pocket technique (ISPT) in deep corneal opacities and lenticular opacities, whereas the intrastromal needle puncture technique (ISNT) was used in superficial opacities or corneoiridic scars. The records of 463 patients were reviewed and analyzed for the duration of the past 7 years.

RESULTS

Two hundred and ninety-three (63.2%) patients underwent ISNT, eight underwent combined technique, and the rest underwent ISPT. The postoperative follow-up period showed more watering and redness in the needle puncture technique (p > 0.001), which resolved in 70.4% of patients by the end of 4 weeks. Repeat procedures were required in 5.3% of the patients with ISNT. The patient's satisfaction grading showed excellent levels in 375 (80.9%) patients, 45 (9.7%) had good satisfaction levels, and the rest had average satisfaction levels.

CONCLUSION

Intrastromal keratopigmentation is a boon for unsightly corneal scars and gives respite to the patients from the social stigma.

Selective Endothelialectomy in Peters Anomaly: A Novel Surgical Technique and Its Clinical Outcomes in Children

PURPOSE

This study describes the surgical outcomes of selective endothelialectomy in Peters anomaly (SEPA), a relatively new technique to manage Peters anomaly (PA).

METHODS

This study included 34 eyes of 28 children who had a visually significant posterior corneal defect due to PA and underwent SEPA between 2012 and 2019. A selective endothelialectomy from the posterior corneal defect was performed while preserving Descemet membrane. The primary outcome measure was the resolution of corneal opacification. The secondary outcome measures were functional vision, complications, and risk factors for failure.

RESULTS

At a mean postoperative follow-up of 0.96 ± 0.20 years, 29 eyes (85.3%) maintained a successful outcome. Mean preoperative and postoperative best-corrected visual acuities were 2.55 ± 0.13 and 1.78 ± 0.13 ( P < 0.0001), respectively. Ambulatory functional visual improvement was seen in 97%, and 23% attained vision ranging between 20/190 and 20/50. Corneal opacification failed to clear in 5 eyes (15%). Risk factors associated with surgical failure were female sex ( P = 0.006), disease severity ( P < 0.0001), glaucoma ( P = 0.001), and additional interventions after SEPA ( P = 0.002). In multivariate analysis, only disease severity (ie, a type 2 PA) was a significant risk factor for the failure of SEPA. There were no sight-threatening complications.

CONCLUSIONS

SEPA is a safe and effective technique in select cases of posterior corneal defect due to PA. SEPA could be a potential surgical alternative to pediatric keratoplasty or optical iridectomy in children with central corneal opacification smaller than 7 mm due to PA.

Cornea Group of Ophthalmology Branch of Chinese Medical Association. [Chinese expert consensus on pediatric corneal transplantation (2022)]

Pediatric keratoplasty is a highly challenging and demanding procedure in children because of various intraoperative morphologic and functional factors and postoperative complications. However, it remains the only way to promote visual development and to avoid corneal blindness in infants and children with corneal opacities. Corneal transplantation in children is different from that in adults in many aspects, such as surgical techniques and clinical evaluation. Besides, it poses more emphases on the perioperative management and the long-term follow-up, because children are less cooperative when examined and are not readily complaining about symptoms. This article is aimed to provide a consensus concerning the indications, preoperative evaluation, surgical procedures and postoperative management regarding pediatric keratoplasty. The consensus, which is based on the results from discussions and consultations among domestic leading researchers and experts with extensive experiences in the related areas, targets to standardize the procedure of pediatric keratoplasty in clinical practice, to minimize the risk of graft failure and to achieve promising outcomes.

[The research progress of mesenchymal stem cell induction and differentiation into corneal tissue]

Keratopathy is one of the most important blinding eye diseases in the world. Corneal opacity caused by keratopathy can seriously damage visual function. For example, corneal ulcer can lead to perforation and even loss of the eyeball. Although corneal transplantation is a routine treatment in clinical practice, there are not only a serious shortage of corneal donors in our country, but also various complications after keratoplasty that can not be avoided. In recent years, with the rapid development of regenerative medicine, it has been found that mesenchymal stem cells can differentiate into a variety of functional cells including corneal tissue under suitable induction conditions, which has a broad prospect of clinical application. This finding provides new ideas and methods for the treatment of keratopathy and corneal blindness in many aspects. This article reviews the research status of induction methods of mesenchymal stem cells in various specialties, particularly in the corneal subspecialty.

[Clinical analysis of penetrating keratoplasty for infants with congenital corneal opacity]

Objective: To investigate the corneal graft survival and related risk factors of primary penetrating keratoplasty in congenital corneal opacity infants. Methods: It was a retrospective cohort study. Data were collected from forty-two infants (51 eyes) who were aged ≤12 months and diagnosed with congenital corneal opacity in Beijing Tongren Hospital and Beijing Anzhen Hospital from January 1, 2017 to January 31, 2018. The mean age at surgery was (5.7±2.2) months (3-12 months). The mean follow-up duration was (28.6±2.6) months (24-33 months). All the patients underwent penetrating keratoplasty. The status of the corneal grafts and complications were observed and recorded during the regular follow-up. The survival probabilities were estimated by using the Kaplan-Meier and Log-rank test. The graft survival between different influence factors was analyzed by using the χ² test. Results: The Kaplan-Meier survival rates for penetrating keratoplasty were 84.3% (43/51) at 6 months, 78.4% (40/51) at 12 months and 60.8% (31/51) at the last follow-up. The presence of corneal neovascularization was significantly correlated with graft failure (χ²=5.264, P=0.022). The graft survival differed between eyes receiving combined surgery and mere penetrating keratoplasty and in eyes with varied surgical indications (P=0.039, <0.01). Increased intraocular pressure (7 eyes, 13.7%) and persistent epithelial defects (7 eyes, 13.7%) were the most common postoperative complications, followed by complicated cataract (4 eyes, 7.8%) and posterior capsule opacification (2 eyes, 3.9%). Conclusions: The graft survival rate was satisfactory following pediatric keratoplasty although it had a tendency to decrease with the follow-up time. Corneal neovascularization was a major risk factor of graft failure. Surgical indications and procedures also had a certain effect on the graft survival.

Surgical approach in type II Peters anomaly – case report

Objective: The aim of this report was to present a rare case of apparently unilateral Peters anomaly and describe the clinical characteristics, surgical approach, and visual prognosis.

Methods: We presented the case of a 7-year-old female patient with posterior corneal defect due to kerato-lenticular adhesions along with anterior dislocation and opacification of the lens in the left eye and a history of post-traumatic evisceration of the right eye. Systemic associations included mental underdevelopment, left torticollis and scoliosis. No family history of acquired or inherited diseases were determined. We performed cataract extraction in the left eye and opted for aphakia.

Results: Based on clinical findings, we considered unilateral Peters anomaly type II. Cataract surgery slightly improved the visual acuity from hand moving to 20/ 400 UCVA (uncorrected visual acuity) and 20/ 100 with +10.0 diopters at 1 month postoperative. No enlargement of the corneal opacity was observed.

Conclusions: In this case, we were able to diagnose Peters anomaly only in one eye. The diagnosis required long follow-up with periodic measurement of intraocular pressure (IOP) to early detect glaucoma. The complexity and uniqueness of the case relied on the difficult approach made by the cloudy cornea and anterior lens dislocation. We applied a combination of techniques including adhesiolysis, cataract extraction and anterior vitrectomy. Further interventions such as secondary IOL (intraocular lens) implantation or PKP (penetrating keratoplasty) will be taken into consideration after six-month and one-year postoperative follow-up.

Abbreviations: PA = Peters anomaly, DM = Descemet’s membrane, IOL = intraocular lens, VA = visual acuity, OVDs = ophthalmic viscosurgical devices, IOP = intraocular pression, PKP = penetrating keratoplasty, BCVA = best corrected visual acuity, UCVA = uncorrected visual acuity

[Optical rehabilitation and pediatric ophthalmological care following keratoplasty for childhood corneal opacities]

BACKGROUND

The younger the children are at the time of corneal transplantation, the worse the survival prognosis of the graft.

PREOPERATIVE CONSIDERATIONS

Preoperative considerations are significant in terms of accurate parental education, ensuring adherence to treatment and choosing the appropriate surgical time frame (amblyopia versus graft failure, compliance of the patient). Parental education must include the reduced visual prognosis in young children, exceptions being later acquired corneal pathologies such as inflammatory corneal scars (herpes) and keratoconus.

POSTOPERATIVE CARE

A distinction must be made between morphological care after transplantation and refractive correction as well as treatment of amblyopia. The younger the children, the less favorable the prognosis for the transplant and the more often multiple examinations with anesthesia are necessary in order to detect complications, such as infiltrates or suture loosening at an early stage. Especially unilateral congenital pathologies often do not lead to a sufficient improvement of amblyopia (refractory amblyopia, poor compliance).

CONCLUSION

The prognosis after keratoplasty in childhood is already partly decided by the careful evaluation of indications (no surgery of a sclerocornea) and the detailed and realistic clarification for the parents (cooperation with long-term ocular and systemic treatment even if the child has poor compliance, frequent check-ups, reduced chances of amblyopia treatment). The younger the child is at the time of transplantation, the more frequent are graft failure and the development of complications. Later manifesting diseases in older children (herpetic corneal scars, keratoconus) have a better prognosis.

Case report of the rare Peters' anomaly complicated with Axenfeld-Rieger syndrome: A case report and brief review of the literature

INTRODUCTION

Peters' anomaly (PA) and Axenfeld-Rieger syndrome (ARS) are typical classifications of anterior segment dysgenesis (ASD) and ascribed to congenital eye diseases that encompass developmental defects in anterior segment structures. The aim of this study is to discuss the unusual association between PA and ARS and to determine the results of penetrating keratoplasty combined with extracapsular cataract extraction and anterior vitrectomy for this unusual ophthalmic phenotype.

PATIENT CONCERNS

A 72-year-old female was referred to Changzhou No. 2 People's Hospital for a progressive decrease in visual acuity in both eyes in the past few decades.

DIAGNOSES

The patient was diagnosed with PA with cone-shaped polar cataracts in the left eye based on a series of ophthalmic examinations. ARS with retinal detachment was diagnosed in the right eye 2 years prior.

INTERVENTIONS

Penetrating keratoplasty combined with extracapsular cataract extraction and anterior vitrectomy were performed to manage PA with cataracts in the left eye.

OUTCOMES

Her best corrected visual acuity did not improve significantly after the operation. Patients with ARS and PA should be treated cautiously because of fundus lesions.

CONCLUSION

This study revealed that cases with PA accompanied by iridocorneal adhesions, or other ocular anomalies, need to be treated cautiously for a very low success rate. It is of reference value for the evaluation of treatment prognosis for this joint occurrence of ophthalmic phenotypes.

[Comparative evaluation of the results of one- and two-piece mushroom keratoplasty]

PURPOSE

To compare and evaluate the outcomes of one- and two-piece mushroom keratoplasty configurations for various corneal pathologies.

MATERIAL AND METHODS

A total of 32 patients (32 eyes) with corneal perforations, descemetocele and deep corneal opacities underwent surgery. Depending on the surgery technique, the patients were divided into 2 groups: group I (17 eyes) underwent manual one-piece mushroom keratoplasty according to our own technique; group II (15 eyes) underwent modified two-piece microkeratome-assisted mushroom keratoplasty according to the technique by M. Busin. All patients underwent clinical and functional studies before surgery and in the course of a 1-year follow-up.

RESULTS

Transparent engraftment of the cornea was achieved in 82 and 80% of cases; best corrected visual acuity (BCVA) averaged 0.57±0.19 and 0.53±0.17; spherical component of refraction varied from 1.25 to +5.5 and from 1.25 to 6.0 diopters; mean corneal astigmatism was 3.15±1.73 and 3.21±1.89 diopters in groups I and II, respectively. At 6 months after surgery, the mean endothelial cell density (ECD) was 2336±198 and 2291±175 cells/mm², at 1 year - 2041±189 and 1955±161 cells/mm² in groups I and II, respectively.

CONCLUSION

One- and two-piece mushroom keratoplasty is effective in surgical treatment of various corneal pathologies ensuring a high rate of transparent corneal engraftment. The revealed risk of false chambers formation between separate parts of the graft after the two-piece method could in most cases be eliminated by re-injecting air into the anterior eye chamber.

Long-term Experience and Visual Acuity Outcomes in Patients With Peters Anomaly

PURPOSE

To report the results from a cases series of patients with Peters anomaly and propose management and treatment approaches according to the alterations associated with each case.

METHODS

The records of 27 patients (32 eyes) clinically diagnosed as having Peters anomaly were analyzed retrospectively. Each patient underwent different treatment modalities (from medical follow-up consultations to penetrating keratoplasty procedures) according to the type of Peters anomaly.1 Results: Of 32 eyes of 27 patients (74% male and 26% female), 5 patients (18.5%) were bilateral and 22 (81.5%) were unilateral. The average number of years of follow-up consultations was 10.2 years (range: 3.5 to 18 years). The long-term visual acuity (VA) results correlated directly with the type of Peters anomaly. Mean VA for all patients was 1.71 ± 1.04 logarithm of the minimum angle of resolution (logMAR). The results by group were 0.30 ± 0.00 logMAR for type I Peters anomaly with only medical monitoring, 0.97 ± 0.78 logMAR for type I Peters anomaly with only optical iridectomy, 1.22 ± 0.97 logMAR for type I Peters anomaly with penetrating keratoplasty, 2.41 ± 0.80 logMAR for type II Peters anomaly without a compromised posterior pole with penetrating keratoplasty, and 2.56 ± 0.48 logMAR for type II Peters anomaly with a compromised posterior pole with penetrating keratoplasty.

CONCLUSIONS

The VA result and long-term corneal failure is directly related to the type of Peters anomaly. Patients with type I Peters anomaly who only required medical follow-up consultations had the most favorable prognosis. Patients in whom penetrating keratoplasty was performed had a poor prognosis. [J Pediatr Ophthalmol Strabismus. 2021;58(5):304-310.].

Short-Term Outcomes of Pediatric Keratoprosthesis With the Near-Complete Conjunctival Flap

PURPOSE

The Boston keratoprosthesis (KPro) has been used for certain indications in pediatric patients with congenital corneal opacities. Here, we describe the use of a near-complete conjunctival flap at the time of Boston type 1 KPro surgery in pediatric patients, with the goal of improving pediatric KPro outcomes.

METHODS

We performed a retrospective chart review of 21 eyes from 16 patients who received their first KPro before the age of 18 years at a tertiary care center in Rochester, NY. Surgeries were performed between 2011 and 2017 (3 years before and after the incorporation of a conjunctival flap, which began in 2014 as part of the pediatric KPro procedure). Patients who had a minimum 1-year postoperative follow-up, or had corneal melts within 1 year of KPro implantation, were included in our study. The main outcome measure in this study was a comparison of the number of complications that required surgical intervention, including retroprosthetic membrane, corneal melt, retinal detachment, and endophthalmitis, in eyes that received KPro implantation without a conjunctival flap compared with eyes that received KPro implantation with a conjunctival flap. Change in the visual acuity up to 1 year postoperatively was also measured.

RESULTS

Ten eyes received KPro with no conjunctival flap, and 11 eyes received KPro with a near-complete conjunctival flap. After 1-year postoperative follow-up, eyes receiving a KPro with a conjunctival flap had fewer KPro-related complications requiring surgical intervention (5 vs. 16, P = 0.0002). Corneal melt was seen in 2 of 11 (18%) eyes in the conjunctival flap group and 5 of 10 (50%) eyes in the nonflap group (P = 0.12). No eyes developed endophthalmitis in the flap group, whereas 1 of 10 (10%) eyes developed endophthalmitis in the nonflap group. Visual acuity at 1-year follow-up improved in 9 of 11 (82%) eyes in the flap group compared with 5 of 10 (50%) eyes in the nonflap group (P = 0.3).

CONCLUSIONS

Implementation of a conjunctival flap in pediatric KPro may help decrease the short-term postoperative complications requiring surgical procedures and may lead to improved visual acuity after 1 year. Further investigation, including longer-term follow-up, is needed to better understand how the described technique affects surgical outcomes in children.

Assessment of Corneal Haze After PRK and the Effect of Sutureless Amniotic Membrane Graft by Corneal Densitometry

PURPOSE

To assess whether densitometry analysis appropriately monitors the development of haze in myopic patients after photorefractive keratectomy (PRK) when compared to subjective slit-lamp haze grade examinations, and whether sutureless cryo-preserved amniotic membrane reduced postoperative haze development when compared to the standard bandage contact lens.

METHODS

In this retrospective cohort at the Center for Refractive Surgery, Walter Reed National Military Medical Center, a secondary analysis of prospectively collected data was performed. In the prospective study, participants underwent PRK for myopia. Postoperatively, a standard bandage contact lens was applied to the dominant eye and a sutureless cryo-preserved amniotic membrane graft to the nondominant eye. Participants were evaluated at 1, 3, and 6 months postoperatively for haze formation and corneal densitometry using slit-lamp biomicroscopy and Scheimpflug imaging, respectively.

RESULTS

Densitometry measurements at 6 months postoperatively were positively and significantly associated with the presence or absence of haze as assessed by slit-lamp examination in 39 patients (78 eyes; age range: 21 to 44 years). Eyes with increased densitometry measurements had 2.3 to 3.4 times the odds (P ⩽ .014) of having clinical haze on slit-lamp examination. Eyes with the amniotic membrane graft showed a positive correlation with increased corneal densitometry throughout most layers of the cornea.

CONCLUSIONS

Densitometry analysis appears to be a useful tool to supplement slit-lamp examination in monitoring haze development after PRK. The amniotic membrane failed to show a reduction in corneal densitometry in myopic eyes after PRK. [J Refract Surg. 2020;36(5):293-299.].

Role of Microscope-Intraoperative Optical Coherence Tomography in Pediatric Keratoplasty: AComparative Study

PURPOSE

We evaluate the role of microscope-integrated intraoperative optical coherence tomography (i-OCT) in pediatric keratoplasty.

DESIGN

Combined prospective and retrospective, comparative, interventional study conducted at the Dr Rajendra Prasad Center for Ophthalmic Sciences in New Dehli, India.

METHODS

Seventy-five children ≤16 years of age undergoing planned keratoplasty were divided into 2 groups and compared regarding intraoperative course and postoperative outcome. In group 1 (prospective group, n = 56), preoperative anterior segment visualization was performed clinically, with ultrasound biomicroscopy (UBM) and i-OCT and keratoplasty was commenced under i-OCT microscope. In group 2 (retrospective group, n = 19), a conventional microscope was used during keratoplasty.

RESULTS

In group 1, i-OCT, UBM, and clinical examination detected retrocorneal membrane in 10%, 7.5%, and 5% (P = .005), iris adhesions in 62.5%, 57.5%, and 20% (P = .02), iris stump in aniridia 15%, 10%, and 0% (P = .001), shallow central anterior chamber in 22.5%, 22.5%, and 7.5% (P = .003), and shallow peripheral anterior chamber in 65%, 60%, and 17.5% (P = .004) of children, respectively. The use of i-OCT affected intraoperative surgeon decision making in 45% and 33% of cases of anterior and posterior lamellar keratoplasty, respectively. During penetrating keratoplasty, concomitant intraoperative procedures were higher in group 1 than in group 2, namely synechiolysis (19/40 vs 2/15; P = .1), pupilloplasty (4/40 vs 0/15; P = .02), lens extraction (4/40 vs 1/15; P = .5), and anterior vitrectomy (2/40 vs 1/15; P = .4). Postoperative secondary interventions were lower (P = .04) in group 1 (48.21% vs 94.74%).

CONCLUSIONS

Anterior segment imaging with i-OCT and UBM immediately before surgery improves the surgical planning of children with corneal opacities. In addition, the use of i-OCT refines intraoperative steps, thereby optimizing the postoperative outcome of pediatric keratoplasty.

Long-Term Visual Outcome in Surgical Management of Cataract Coexistent With Corneal Opacity in One-Eyed Patients

PURPOSE

To determine the visual outcome and safety of cataract surgery alone and compare with the long-term visual outcome of triple procedure in one-eyed patients.

DESIGN

Retrospective study.

METHODS

This study reviewed 44 one-eyed patients with cataract coexistent with corneal opacity. The patients who underwent cataract surgery alone (group A, n = 25) were compared with patients managed by triple procedure (group B, n = 19). Outcome measures were the improvement of best corrected visual acuity (BCVA) and period of maintained ambulatory vision. Institutional ethics committee approval was obtained.

RESULTS

The most common etiology of corneal opacity was fungal and the commonest cause of permanent visual loss in other eye was phthisis bulbi. Mean age was 61.2 ± 8.1 years and 62.5 ± 6.9 years in groups A and B, respectively. At each follow-up, the mean postoperative BCVA was found significantly better than the preoperative vision in both groups and at the end of 3 years, mean postoperative vision of group A was better than that of group B (P = 0.012). Group A had longer (33.36 ± 11.97 months) mean period of maintained ambulatory vision than that of group B (26.5 ± 13.5 months) (P = 0.245) and showed less risk of losing ambulatory vision. Limited visual outcome was due to continuing presence of corneal opacity in group A, and graft infection and graft rejection in group B.

CONCLUSIONS

Cataract surgery with intraocular lens (IOL) implantation alone can be considered as an alternative or temporary option to provide stable ambulatory vision in one-eyed patients.

Primary Pediatric Keratoplasty: Etiology, Graft Survival, and Visual Outcome

PURPOSE

Interventional study to evaluate the etiology, visual outcome and survival of corneal transplantation in children and to identify the risk factors associated with graft failure.

DESIGN

Retrospective, interventional consecutive case series.

METHODS

Medical records of every child 7 years of age or younger who underwent primary penetrating keratoplasty at Department of Ophthalmology, Federal University of São Paulo were reviewed. The parameters evaluated were indications for keratoplasty, graft survival, and postoperative visual acuity (VA) improvement. Children underwent ophthalmologic examination before and after corneal graft, including VA, assessed by the preferential looking test and visual evoked potential. The analysis of transplant survival was performed using the Kaplan-Meier method.

RESULTS

Fifty-six penetrating transplants were performed in 51 eyes of 43 children. The patients were divided into 2 groups: congenital (72.5%) and acquired (17.5%) corneal opacity. The main indication was congenital glaucoma (29.4%). The overall Kaplan-Meier graft survival rates were 64.7% in the postoperative average follow-up period of 24 months. There was no significant difference in graft survival between the congenital and acquired groups (Mantel-Cox P = .1031). There was significant improvement in VA in both groups (P = .0022 for congenital and P < .0001 for acquired). Rejection and diagnosis of congenital glaucoma were risk factors for graft failure.

CONCLUSIONS

Congenital glaucoma was the main indication for corneal transplantation and despite the difficulties, prolonged survival and improved VA can be achieved in pediatric transplant. Complications such as rejection and early glaucoma were significantly associated with graft failure.

A Novel Surgical Approach in the Management of Peters Anomaly With Glaucoma

Treatment options for Peters anomaly vary depending on the degree of corneal and lenticular involvement. The authors report a novel surgical approach for patients with type I Peters anomaly and glaucoma. It involves ab externo circumferential trabeculotomy, simultaneous lysis of iridocorneal adhesions at the time of trabecular cleavage, and optical iridectomy. [J Pediatr Ophthalmol Strabismus. 2020;57:e25-e29.].

Clinicopathologic Features and Treatment Characteristics of Congenital Corneal Opacity Infants and Children Aged 3 Years or Less: A Retrospective Single Institution Analysis

OBJECTIVE

In this retrospective single institution study, we investigated the clinicopathologic features and treatment characteristics of 90 patients with congenital corneal opacities (CCO) (117 eyes) who were 3 years and younger and treated at our hospital.

SUBJECT AND METHODS

We reviewed the clinical data of patients with CCO who presented for the first time for treatment at our hospital between January 1, 2017, and December 31, 2017. CCO were classified using the "STUMPED" (Sclerocornea, Tears in Descement's membrane, Metabolic, Peters, Endothelial dystrophy and Dermoid) method and confirmed by pathological examination. -Results: Seventy percent of the patients had unilateral CCO. Iridocorneal adhesions (61 eyes, 52.1%) and cataracts (22 eyes, 18.8%) were the 2 most common ocular abnormalities. Systemic abnormalities were present in 5 patients (5.6%), including growth retardation (4 patients) and congenital brain defects (1 patient). Eighty-five eyes (72.6%) underwent penetrating keratoplasty (PK), and lamellar keratoplasty (LK) was performed in 30 (25.6%) eyes. Forty-seven (95.9%) eyes with Peters anomaly and all 16 eyes with sclerocornea received PK, and all 24 eyes with dermoids were treated with LK.

CONCLUSION

Our study demonstrates that CCO has varied manifestations in infants and young children in China. A thorough medical history, careful clinical examination, and the use of accessory examinations such as ultrasound biomicroscopy are critical for the accurate diagnosis and classification of CCO and to provide guidance on therapeutic choices.

Twenty five-gauge endoscopic vitrectomy for proliferative vitreoretinopathy with severe corneal opacity

PURPOSE

To report 4 cases undergoing 25-gauge endoscopic vitrectomy for the treatment of proliferative vitreoretinopathy with severe corneal opacity in which a transpupillary view of the fundus was not possible.

STUDY DESIGN

A retrospective interventional case series.

METHODS

The main outcomes measured were postoperative anatomic status of the retina and subjective improvement of vision.

RESULTS

Postoperative reattachment of the retina and subjective improvement of vision were achieved in all 4 eyes.

CONCLUSION

Twenty five-gauge endoscopic vitrectomy provides a clear view making it possible conduct pars plana vitrectomy in order to reattach the retina in cases of proliferative vitreoretinopathy with severe corneal opacity.

Paraproteinemic keratopathy in monoclonal gammopathy of undetermined significance treated with primary keratoprosthesis: Case report, histopathologic findings, and world literature review

RATIONALE

We report a case of paraproteinemic keratopathy associated with monoclonal gammopathy of undetermined significance, treated with keratoprosthesis as a primary penetrating procedure. Histopathological findings and a world literature review are presented.

PATIENT CONCERNS

A 74 year old female recently diagnosed with monoclonal gammopathy undetermined significance presented with progressive blurry vision bilaterally.

DIAGNOSES

Examination revealed corneal opacities consistent with paraproteinemic keratopathy.

INTERVENTIONS

Corneal transplantation with the Boston Type I keratoprosthesis was performed on the right and, a year later, on the left.

OUTCOMES

Visual outcomes were good. Histopathological staining of host corneal buttons were consistent with monoclonality, and electron microscopy revealed fibrillar extracellular aggregates within intervening normal stroma.

LESSONS

Corneal deposits may be the only manifestation of monoclonal gammopathy of undetermined significance in patients who are otherwise systemically asymptomatic. Ophthalmologists who encounter corneal opacities may order the appropriate diagnostic studies to determine the presence of occult systemic disease. Risk of graft failure after penetrating keratoplasty from recurring opacities is high, so keratoprosthesis as a primary penetrating procedure may afford superior long-term outcomes. Host corneal buttons retrieved from penetrating keratoplasty or corneal biopsy may be sent for histopathological examination to confirm the diagnosis.

Temporal and spatial analysis of stromal cell and extracellular matrix patterning following lamellar keratectomy

Extracellular matrix (ECM) supplies both physical and chemical signals to keratocytes which can impact their differentiation to fibroblasts and/or myofibroblasts. It also provides a substrate through which they migrate during wound repair. We have previously shown that following transcorneal freeze injury (FI), migrating corneal fibroblasts align parallel to the stromal lamellae during wound repopulation. In this study, we compare cell and ECM patterning both within and on top of the stroma at different time points following lamellar keratectomy (LK) in the rabbit. Twelve rabbits received LK in one eye. Rabbits were monitored using in vivo confocal microscopy at 3, 7, 21 and 60 days after injury. A subset of animals was sacrificed at each time point to further investigate cell and matrix patterning. Tissue was fixed and labeled in situ with Alexa Fluor 488 phalloidin (for F-actin), and imaged using multiphoton fluorescence and second harmonic generation (SHG) imaging (for collagen). Immediately following LK, cell death occurred in the corneal stroma directly beneath the injury. At 7 and 21 days after LK, analysis of fluorescence (F-actin) and SHG results (collagen) indicated that fibroblasts were co-aligned with the collagen lamellae within this region. In contrast, stromal cells accumulating on top of the stromal wound bed were randomly arranged, contained more prominent stress fibers, and expressed alpha smooth muscle actin (α-SMA) and fibronectin. At 60 days, cells and matrix in this region had become co-aligned into lamellar-like structures; cells were elongated but did not express stress fibers. Corneal haze measured using in vivo confocal microscopy peaked at 21 days after LK, and was significantly reduced by 60 days. Cell morphology and patterning observed in vivo was similar to that observed in situ. Our results suggest that the topography and alignment of the collagen lamellae direct fibroblast patterning during repopulation of the native stroma after LK injury in the rabbit. In contrast, stromal cells accumulating on top of the stromal wound bed initially align randomly and produce a fibrotic ECM. Remarkably, over time, these cells appear to remodel the ECM to produce a lamellar structure that is similar to the native corneal stroma.

The Palisades of Vogt in Congenital Corneal Opacification (An American Ophthalmological Society Thesis)

PURPOSE

The purposes of this study are first, to determine if the palisades of Vogt (POV) are present or absent in cases of congenital corneal opacification (CCO) by using spectral domain ocular coherence tomography (SD-OCT), and second, in those cases already undergoing penetrating keratoplasty (PKP), to see whether the absence or presence of POV corresponds to re-epithelialization following transplant.

METHODS

This was a retrospective case review of 20 eyes (10 normal, 10 with CCO) evaluated with SD-OCT. The operator was masked to the clinician's assessment of the ocular surface. In those cases where the decision to perform PKP had already been made, the correlation between POV presence or absence and posttransplant graft epithelialization was determined.

RESULTS

All cases were imaged without adverse event. Nine eyes showed some evidence of POV and corresponding vasculature. Eight of 10 affected eyes underwent PKP, and subsequently 7 eyes epithelialized and 2 showed some peripheral neovascularization. The one eye that showed no signs of POV was the one that failed to epithelialize. All control subjects had consistent and regular POV.

CONCLUSIONS

Congenital corneal opacification is rare, and this study shows that at least some POV are present in the majority of cases of CCO. However, the palisades may not be entirely normal compared to age-matched controls. When there was absence of POV in a case of CCO, there was immediate and complete failure of epithelialization.

[Analysis of clinic results and complication associated with Boston I keratoprosthesis]

OBJECTIVE

This study was to evaluate clinical results and complications associated with the Boston type I keratoprosthesis implanted into complex corneal opacity.

METHODS

Retrospective study. Sixty-one eyes (57 cases) received Boston type I KPro implantation between May 2011 and January 2013 in the Chinese PLA General Hospital, and were followed for at least 2 months (range, 2 to 27 months, mean 19 months). Indications for keratoprosthesis included thermal injury (n = 17), chemical injury (n = 19), herpetic keratitis (n = 8), blast injury (n = 6), keratitis (n = 8), antoimmune diseases (n = 2) and corneal endothelial decompensation (n = 9). Kpro implantation in accordance with the Massachusetts Eye Center standardized surgical approach, and routine lens removal meantime. Clinical complications and postoperative treatments were recorded.

RESULTS

Preoperative visual acuity were light perception to the counting figure in all the patients. Forty-seven eyes (77%) had better best correct visual acurity than counting figure and 18 eyes (30%) had BCVA better than 0.3 after implantation. Postoperative complications indluded carrier corneal melting (10 cases), retroprothesis membrane (6 cases), glaucoma (12 cases), retinal detachment (2 cases), choroidal detachment (1 case), endophthalmitis (2 cases). Complications take symptomatic treatment, in addition to glaucoma patients and two cases of endophthalmitis patients (Evisceration), all patients can maintain the original best corrected visual acuity.

CONCLUSIONS

Timely examination of the KPro and replacement with donor cornea may prevent a poor outcome. Close follow-up is necessary after KPro-implantation.

Boston Keratoprosthesis: Outcomes and Complications: A Report by the American Academy of Ophthalmology

OBJECTIVE

To review the published literature on safety and outcomes of the Boston type I keratoprosthesis (BI-KPro) for the surgical treatment of corneal opacification not amenable to human cadaveric corneal transplantation.

METHODS

Searches of peer-reviewed literature were conducted in PubMed and the Cochrane Library in December 2012, July 2013, and January 2014 without date restrictions. The searches were limited to studies published in English and yielded 587 citations. The abstracts of these articles were reviewed, 48 articles were selected for possible clinical relevance, and 22 were determined to be relevant for the assessment objectives. Nine studies were rated as level II evidence and 13 studies were rated as level III evidence. Excluded were level III evidence, case reports, review articles, letters, editorials, and case series with fewer than 25 eyes.

RESULTS

In 9 articles, a best-corrected Snellen visual acuity (BCSVA) of 20/200 or better occurred in 45% to 89% of eyes. Five articles described a BCSVA of 20/50 or better in 43% to 69% of eyes, and 4 articles found a BCSVA of 20/40 or better in 11% to 39% of eyes. Retention rates of the BI-KPro ranged from 65% to 100%. Reasons for loss of vision after BI-KPro implantation most commonly included corneal melts resulting from exposure keratopathy, endophthalmitis, and infectious keratitis or corneal ulceration. The 2 most common complications after surgery were retroprosthetic membrane formation (range, 1.0%-65.0%; mean ± standard deviation [SD], 30.0±19.0%) and elevated intraocular pressure (range, 2.4%-64.0%; mean ± SD, 27.5±18.1%). The 2 most common posterior segment complications were endophthalmitis (range, 0%-12.5%; mean ± SD, 4.6±4.6%) and vitritis (range, 0%-14.5%; mean ± SD, 5.6±4.7%).

CONCLUSIONS

The reviewed articles on BI-KPro use suggest that the device improves vision in cases of severe corneal opacification that were not amenable to corneal transplantation using human cadaveric keratoplasty techniques. A number of severe anterior and posterior segment complications can develop as follow-up continues, making ongoing close observation paramount for patients undergoing this surgery. These complications include infection, device extrusion, and permanent vision loss.

A Two-Piece Microkeratome-Assisted Mushroom Keratoplasty Improves the Outcomes and Survival of Grafts Performed in Eyes with Diseased Stroma and Healthy Endothelium (An American Ophthalmological Society Thesis)

PURPOSE

To test the hypothesis that a new microkeratome-assisted penetrating keratoplasty (PK) technique employing transplantation of a two-piece mushroom-shaped graft may result in better visual outcomes and graft survival rates than those of conventional PK.

METHODS

Retrospective chart review of 96 eyes at low risk and 76 eyes at high risk for immunologic rejection (all with full-thickness central corneal opacity and otherwise healthy endothelium) undergoing mushroom PK between 2004 and 2012 at our Institution. Outcome measures were best-corrected visual acuity (BCVA), refraction, corneal topography, endothelial cell density, graft rejection, and survival probability.

RESULTS

Five years postoperatively, BCVA of 20/40 and 20/20 was recorded in 100% and over 50% of eyes, respectively. Mean spherical equivalent of refractive error did not vary significantly over a 5-year period; astigmatism averaged always below 4 diopters, with no statistically significant change over time, and was of the regular type in over 90% of eyes. Endothelial cell density decreased to about 40% of the eye bank count 2 years after mushroom PK and did not change significantly thereafter. Five years postoperatively, probabilities of graft immunologic rejection and graft survival were below 5% and above 95%, respectively. There was no statistically significant difference in endothelial cell loss, graft rejection, and survival probability between low-risk and high-risk subgroups.

CONCLUSIONS

Refractive and visual outcomes of mushroom PK compare favorably with those of conventional full-thickness keratoplasty. In eyes at high risk for immunologic rejection, mushroom PK provides a considerably higher probability of graft survival than conventional PK.

Use of intraocular video endoscopic examination in the preoperative evaluation of keratoprosthesis surgery to assess visual potential

PURPOSE

To determine the clinical utility of intraocular videoendoscopy examination for the evaluation of the retina and optic nerve in patients being considered for a Boston type I keratoprosthesis (KPro).

DESIGN

Interventional case series study.

METHODS

Ten patients with a history of corneal blindness caused by failed penetrating keratoplasty (PK) and inability to accurately assess visual potential were included in this study. Ophthalmologic examination, B-scan ultrasonography, and pars plana videoendoscopy were carried out to assess the retina and optic nerve before KPro.

RESULTS

Posterior segment examination was successfully used to evaluate the retina and optic nerve of all patients with opaque corneas. Out of 10 patients that underwent endoscopic examination, 3 (30%) were considered to be adequate candidates for KPro surgery and 7 (70%) were not. This was based on visualized retinal disease and/or optic nerve pathology. Of the 3 patients that underwent KPro surgery, all of them had a significant improvement of vision, including counting fingers to 20/100, hand motion to 20/5, and light perception to 20/80, as suggested by the endoscopy preoperative examination. No complications of the endoscopy procedure were observed.

CONCLUSIONS

This report demonstrates the successful use of intraocular videoendoscopy to rule out threats to a good visual outcome for patients being considered as candidates for KPro. Direct visualization of the posterior segment can be part of the preoperative algorithm in the decision process of performing a KPro surgery in patients when visual potential is questionable.

[Evaluation of endoscopy assisted vitrectomy for the treatment of severe traumatic eyes with no light perception]

OBJECTIVE

To evaluate the effect of endoscopy assisted pars plana vitrectomy for severe ocular trauma with no light perception.

METHODS

A retrospective case-series study. Medical records of 6 eyes of 6 patients undergoing endoscopy assisted vitrectomy for severe ocular trauma with no light perception from December 2006 to August 2009 were studied. Four patients were male and 2 patients were female. Their age ranged from 6 to 67 years old with an mean age of 38 years. History of trauma, visual acuity prior to vitrectomy and at final follow-up, bacterial culture results and surgical approaches were recorded.

RESULTS

Visual acuity prior to vitrectomy was no light perception in all the 6 patients with a mean intraocular pressure of 3 mmHg (1 mmHg=0.133 kPa) . All the patients had diffuse corneal edema along with opacities caused by corneal perforation from trauma in 3 patients, blood staining of cornea in 2 patients and endophthalmitis in 1 patient. B-scan ultrasound echography carried out before surgery showing that all the patients had retinal detachment. Three patients' vitreous samples were sent for bacterial culture. Bacillus cereus, S.epidermidis and Aeromonas Hydrophila were identified respectively. Patients were followed up for 18 to 36 months. Postoperatively, 5 of the patients' visual acuity was better than light perception, ranging from light perception to 0.04. The retina was reattached in 4 patients.

CONCLUSION

Endoscopy assisted vitrectomy is a safe and effective option for the treatment of severe traumatic eye with no light perception.

Predicting transepithelial phototherapeutic keratectomy outcomes using Fourier domain optical coherence tomography

PURPOSE

The aim of this study was to use Fourier domain optical coherence tomography to predict transepithelial phototherapeutic keratectomy outcomes.

METHODS

This is a prospective case series. Subjects with anterior stromal corneal opacities underwent an excimer laser phototherapeutic keratectomy (PTK) combined with a photorefractive keratectomy using the VISX S4 excimer laser (AMO, Inc, Santa Ana, CA). Preoperative and postoperative Fourier domain optical coherence tomography images were used to develop a simulation algorithm to predict treatment outcomes. Main outcome measures included preoperative and postoperative uncorrected distance visual acuities and corrected distance visual acuity.

RESULTS

Nine eyes of 8 patients were treated. The nominal ablation depth was 75 to 177 μm centrally and 62 to 185 μm peripherally. Measured PTK ablation depths were 20% higher centrally and 26% higher peripherally, compared with those for laser settings. Postoperatively, the mean uncorrected distance visual acuity was 20/41 (range, 20/25-20/80) compared with 20/103 (range, 20/60-20/400) preoperatively. The mean corrected distance visual acuity was 20/29 (range, 20/15-20/60) compared with 20/45 (range, 20/30-20/80) preoperatively. The MRSE was +1.38 ± 2.37 diopters (D) compared with -2.59 ± 2.83 D (mean ± SD). The mean astigmatism magnitude was 1.14 ± 0.83 D compared with 1.40 ± 1.18 D preoperatively. Postoperative MRSE correlated strongly with ablation settings, central and peripheral epithelial thickness (r = 0.99, P < 0.00001). Central islands remained difficult to predict and limited visual outcomes in some cases.

CONCLUSIONS

Optical coherence tomography measurements of opacity depth and 3-dimensional ablation simulation provide valuable guidance in PTK planning. Post-PTK refraction may be predicted with a regression formula that uses epithelial thickness measurements obtained by optical coherence tomography. The laser ablation rates described in this study apply only to the VISX laser.

Three-year outcomes of cultured limbal epithelial allografts in aniridia and Stevens-Johnson syndrome evaluated using the Clinical Outcome Assessment in Surgical Trials assessment tool

Limbal stem cell deficiency (LSCD) is an eye disorder in which the stem cells responsible for forming the surface skin of the cornea are destroyed by disease. This results in pain, loss of vision, and a cosmetically unpleasant appearance. Many new treatments, including stem cell therapies, are emerging for the treatment of this condition, but assessment of these new technologies is severely hampered by the lack of biomarkers for this disease or validated tools for assessing its severity. The aims of this study were to design and test the reliability of a tool for grading LSCD, to define a set of core outcome measures for use in evaluating treatments for this condition, and to demonstrate their utility. This was achieved by using our defined outcome set (which included the Clinical Outcome Assessment in Surgical Trials of Limbal stem cell deficiency [COASTL] tool) to evaluate the 3-year outcomes for allogeneic ex vivo cultivated limbal epithelial transplantation (allo-CLET) in patients who had bilateral total LSCD secondary to aniridia or Stevens-Johnson syndrome. The results demonstrate that our new grading tool for LSCD, the COASTL tool, is reliable and repeatable, and that improvements in the biomarkers used in this tool correlate positively with improvements in visual acuity. The COASTL tool showed that following allo-CLET there was a decrease in LSCD severity and an increase in visual acuity up to 12 months post-treatment, but thereafter LSCD severity and visual acuity progressively deteriorated.

Total anterior corneal surface and epithelial stem cell harvesting: current microkeratomes and beyond

Currently, most corneal lamellar allografts are performed by manually dissecting donor corneoscleral material for transplantation. Manual dissection is technically challenging and time intensive, and excessive handling of tissue may decrease the likelihood of obtaining viable grafts. These mechanical factors, along with problems controlling immune rejection, have prevented limbal stem cell lamellar allografts in particular from becoming more widely used. Anterior lamellar keratoplasty is gaining in clinical importance and usage but is still only practiced by a limited number of surgeons. Recently, new mechanical and femtosecond laser microkeratomes have been adapted to harvest the anterior corneal surface, including the limbal stem cell region. Preliminary results have been encouraging and give hope that this technique may prove to be of benefit to patients in the future.

Indications for and outcomes of deep anterior lamellar keratoplasty in mucopolysaccharidoses

PURPOSE

To describe the outcome of deep anterior lamellar keratoplasty (DALK) for visually significant corneal clouding in patients with mucopolysaccharidoses (MPS).

METHODS

A retrospective consecutive case series of patients with MPS and corneal clouding were analyzed at a tertiary eye hospital. A review of the English literature regarding MPS and DALK was performed. The main outcomes measures of the study were intraoperative surgical complications, change in visual acuity, and postoperative DALK-related complications.

RESULTS

Four eyes from 2 patients with MPS I (Hurler's syndrome and Hurler-Scheie syndrome) and a history of DALK met inclusion criteria for the case series. Using the "big-bubble" technique, DALK was performed successfully in all eyes. Completed Descemet's membrane baring was achieved in 3 or 4 eyes and a pre-Descemet's membrane dissection in 1 eye. The mean age at the time of DALK was 17.3 years (range: 15.4 to 19.5 years). Mean follow-up time after DALK was 16.7 months (range: 6 to 31 months). Mean visual acuity before DALK was 20/80 (0.59 ± 0.12 logMAR). Mean visual acuity at the last visit for all 4 eyes was 20/50 (0.41 ± 0.17 logMAR). Visual acuity improved in all eyes. Recurrence of MPS corneal clouding was not noted in any of the corneal grafts.

CONCLUSIONS

DALK is a beneficial and preferable intervention in appropriate patients with significant corneal clouding due to MPS I. Improvement in vision can be obtained with stable, clear corneal grafts, although other ophthalmic manifestations may limit vision.

Long-term visual outcomes of penetrating keratoplasty for Peters anomaly

BACKGROUND

To investigate the long-term results and visual outcomes of penetrating keratoplasty (PKP) in Peters anomaly.

METHODS

Twenty-three eyes from 22 patients with Peters anomaly who underwent PKP from 1998 to 2008 were reviewed retrospectively. Patients who were followed for more than 3 years after the first PKP were included in this study. The systemic and ophthalmic features of the recipients were assessed, and the various prognostic factors for graft survival were evaluated. Disease severity was determined according to other accompanying eye anomalies in mild or severe form. The final visual outcomes were presented with respect to graft clarity.

RESULTS

Among the 22 patients, 14 patients had unilateral disease, and eight patients had bilateral disease. Associated systemic anomalies were observed in six patients. The mean age at the first PKP was 42.4 months. Nineteen eyes (83 %) underwent PKP after 12 months of age. The graft failure rates at 1 year, 3 years, 5 years, and 10 years after PKP were 30 %, 39 %, 70 %, and 77 % respectively. Graft rejection within 1 month after PKP and severe disease were significant risk factors for graft failure. The mean final VAs in the clear-graft group and the failed-graft group were 1.883 logMAR and 2.767 logMAR (P < 0.001).

CONCLUSION

The results of delayed PKP in Peters anomaly were not inferior compared to the results of PKP performed at an earlier period in previous studies. If other congenital ophthalmic anomalies were present or graft rejection occurred within 1 month after PKP, the chance of graft failure was significantly increased.

Corneal hysteresis in mucopolysaccharidosis I and VI

PURPOSE

High intraocular pressure (IOP) and glaucoma are often suspected in patients with mucopolysaccharidosis (MPS). To determine corneal hysteresis (CH) and IOP in children with mucopolysaccharidosis I-Hurler (MPS I-H) and MPS VI.

METHODS

Clinical measurements with ocular response analyzer (ORA).

RESULTS

In seven patients, five with MPS I-H treated with stem cell transplantation (SCT), and two with MPS VI, one treated with SCT and the other with enzyme therapy, the IOP was examined with ORA. Ocular response analyzer measurements were made at a median age of 8.7 years in the patients with MPS I-H and at a median age of 9.3 years in the patients with MPS VI. Earlier measurements had raised suspicion of high IOP in one patient. The ORA showed an increased CH and a falsely high IOP values in all 14 eyes. The recalculated IOPs were normal in all 14 eyes. Mild to severe corneal opacities were present in all 14 eyes. Optic disc areas, borders and cupping were clinically normal in the 12 of 14 eyes that were possible to examine. Severe corneal opacities hampered optic disc evaluation in the older patient with MPS VI. Three eyes in two patients had normal thickness of the retinal nerve fibre layer measured with scanning laser polarimetry with corneal compensation (GDx VCC). No patient was diagnosed or treated for glaucoma.

CONCLUSION

The IOPs are often falsely high because of an increased resistance of the cornea and correlate to the extent of corneal clouding. In this small, cross-sectional study, it appears that corneal resistance is directly correlated with corneal clouding, although a longitudinal study that evaluates resistance as the cornea clears with treatment would provide more direct evidence that corneal deposits are directly related to resistance. A correct measured IOP can avoid unnecessary medical or surgical hypotensive treatment.

Dystrophia Smolandiensis: a novel morphological picture of recurrent corneal erosions

PURPOSE

The aim of this study was to describe morphological changes in Dystrophia Smolandiensis, a corneal disease that is characterized by recurrent corneal erosive episodes and the formation of central corneal keloid-like opacities in approximately half of those affected.

METHODS

The corneas of seven affected individuals were examined using in-vivo confocal microscopy. Specimens of one primary corneal graft, one regraft and one biopsied keloid-like region--all obtained from members of a large family with the disease--were re-examined with a light microscope. Sections were stained with Congo red and analysed immunohistochemically for fibronectin and S100A4.

RESULTS

Light microscopic examination revealed epithelial hyperplasia, absence of Bowman's layer and subepithelial fibrosis. Fibronectin was expressed in the area of subepithelial fibrosis, and the keratocytes in this area generally expressed S100A4. The biopsy specimen stained positive for Congo red, suggesting an amyloid deposit. In-vivo confocal microscopy confirmed epithelial abnormalities, loss of Bowman's layer and significant alterations of the subbasal nerve plexus in affected individuals.

CONCLUSION

The morphological picture in Dystrophia Smolandiensis is novel for a condition dominated by recurrent corneal erosions at the clinical level. Although no single morphological feature unique to the disease could be found, the general morphological pattern of pathology (true keloid formation, absence of Bowman's layer, subepithelial fibrosis and abnormal subbasal nerves) probably reflects a novel phenotypic expression of the healing response to recurrent erosion of the corneal epithelium. However, the pathogenesis of Dystrophia Smolandiensis remains to be elucidated fully.