Key Roles of Conjunctiva Fornix-Bulbar Conjunctiva-Tenon Capsule in Conjoint Fascial Sheath Suspension

BACKGROUND

Bulbar conjunctival prolapse is one of the complications of conjoint fascial sheath (CFS) suspension and has a negative impact on surgical results. To explore the prevention methods of this complication, the authors compared the incidence of it between the below-conjunctiva fornix-bulbar conjunctiva-Tenon capsule (CBT) approach and the above-CBT approach to dissecting CFS in CFS suspension and shared their experience in the treatment of bulbar conjunctival prolapse.

METHODS

From January of 2020 to August of 2021, 81 patients with severe congenital ptosis who underwent CFS suspension were enrolled and divided into two groups. Forty-five patients' (group A) CFS was dissected by means of the below-CBT approach and 36 patients' (group B) CFS was dissected by means of the above-CBT approach. Data regarding the incidence and outcomes of bulbar conjunctival prolapse and the postoperative condition were collected and analyzed.

RESULTS

The incidence of bulbar conjunctival prolapse was 24.44% in group A and 2.78% in group B. Of the 12 bulbar conjunctival prolapse patients, seven patients' conditions improved after conservative treatment, and five did not. All of them underwent bulbar conjunctiva resection within 1 year and were cured. No recurrent prolapse was observed within 3 months postoperatively. At the last follow-up, the mean marginal reflex distance 1 and palpebral fissure height were 4.09 ± 0.19 mm and 9.85 ± 0.62 mm, respectively. There were no complications except lagophthalmos (16 eyelids), asymmetric eyelid contour (one patient), and trichiasis (two eyelids).

CONCLUSIONS

The incidence of bulbar conjunctival prolapse decreased significantly by dissecting CFS by means of the above-CBT approach. For patients with bulbar conjunctival prolapse after CFS suspension, bulbar conjunctiva resection could provide satisfactory results.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

[Epidemiological impact of the COVID-19 pandemic on enucleation cases in Germany]

PURPOSE

To determine the rate of enucleation in Germany and the impact that the COVID-19 pandemic may have had on its characteristics.

METHODS

The rates of enucleation in Germany during 2019 and 2020 were extracted from the diagnosis-related groups (DRG) registry using the operation and procedure classification system codes 5‑163.0 through 5‑163.23 and 5‑163.x. The data were statistically analyzed.

RESULTS

The number of enucleations showed a 16.6% reduction from 1295 cases in 2019 compared to 1080 cases in 2020 (p = 0.17). In both years men averaged 54.1% of cases. Patients older than 65 years represented 53% and 56% of cases in 2019 and 2020, respectively. The most common indication for enucleation in both years was phthisis bulbi (n = 373 and n = 307, respectively), accounting for 29.7% of the cases, followed by choroidal malignancies (24%). Enucleation with the simultaneous introduction of an alloplastic orbital implant into Tenon's capsule represented the most common procedure (38.7% combined 2‑year average), followed by a sheathed variant (26.6%) and a bulbar implant made of nonabsorbable microporous material (16.8%), without a significant change between years. Enucleations without the introduction of an implant increased from 7.8% in 2019 to 11.1% in 2020 (p = 0.006). The proportion of patients undergoing a reoperation slightly increased from 5.6% to 8% (p = 0.018). Most procedures (65.6%) were performed in large (> 1000 beds) public hospitals.

CONCLUSION

Despite the decrease in the total number of procedures performed, the rate of enucleation in Germany was not significantly altered by the COVID-19 pandemic. The rate of enucleation without implants and reoperations significantly increased.

Comparison in conjunctival-Tenon's capsule thickness, anterior scleral thickness and ciliary muscle dimensions between Caucasians and Hispanic by optical coherence tomography

PURPOSE

To investigate the differences in the dimensions of the anterior ocular segment, and specifically in conjunctival-Tenon's capsule thickness (CTT), anterior scleral thickness (AST) and ciliary muscle thickness (CMT), between Caucasian and Hispanic subjects using swept-source optical coherence tomography (SS-OCT).

METHODS

Cross-sectional study including 53 Hispanic and 60 Caucasian healthy participants, matched by age, sex and refractive error, who underwent a complete ophthalmological examination. CTT, AST and CMT were manually measured in the temporal and nasal quadrants at 0, 1, 2 and 3 mm from the scleral spur using SS-OCT.

RESULTS

Mean age and refractive error were 38.7 ± 12.3 years and -1.05 ± 2.6 diopters, and 41.8 ± 11.7 years and -0.50 ± 2.6 diopters for the Hispanic and Caucasians, respectively (p = 0.165 and p = 0.244). The CTT was increased in the temporal quadrant in the Hispanic group in the three studied regions (CTT1, CTT2 and CTT3; being the means 223.0 ± 68.4, 215.3 ± 66.4 and 203.8 ± 67.1 µm versus 190.8 ± 51.0, 189.4 ± 53.2 and 187.4 ± 55.3 µm respectively; p < 0.001). Larger AST values were observed in the temporal quadrant in the Hispanic group (AST2: 559.8 ± 80.8 µm and AST3: 591.6 ± 83.0 µm) compared to the Caucasian group (520.7 ± 50.1 and 558.9 ± 54.7 respectively; p ≤ 0.022). No differences were observed in the nasal quadrant for CTT, AST1 and AST3 (p ≥ 0.076). No differences emerged in the CM dimensions (p ≥ 0.055).

CONCLUSION

CTT and AST measurements were thicker in the temporal quadrant of Hispanic patients compared to Caucasians. This could have implications for the pathogenesis of different ocular diseases.

The Efficacy of Atelocollagen to Inhibit Fibrotic Proliferation in Tenon Tissue: In vitro Study

INTRODUCTION

The aim of the study was to evaluate the safety and efficacy of atelocollagen in preventing the fibrotic change of human tenon tissue induced by transforming growth factor β1 (TGFβ1).

METHODS

Primary cultured human Tenon's fibroblasts (HTFs) were incubated with TGFβ1 alone and with various concentrations of atelocollagen, respectively. Cell viability was measured by Cell Counting Kit-8 (CCK-8). The mRNA levels of α-smooth muscle actin (α-SMA), vimentin, fibronectin, zonular occludens scaffolding protein (ZO-1), cellular communication network factor 2 (CCN2), and interleukin 6 (IL-6) were measured by quantitative reverse transcription polymerase chain reaction, Western blot, and immunofluorescence analysis. Wound healing assay and collagen contraction assay were additionally evaluated for identifying the inhibitory effect of atelocollagen in HTFs. To elucidate the mechanism by which atelocollagen affects HTF proliferation, the phospho-extracellular-signal-regulated kinases (pERK)/total-extracellular-signal-regulated kinases (tERK), phospho-focal adhesion kinase (pFAK)/total-focal adhesion kinase (tFAK), and pSmad3/tSmad3 protein expression ratios were measured by Western blot.

RESULTS

The safety of atelocollagen in HTF was identified by CCK-8 analysis. The expression of α-SMA and vimentin in HTFs treated with 0.023% and 0.046% atelocollagen significantly decreased at both mRNA and protein levels, while that of ZO-1 in 0.046% atelocollagen increased compared with TGFβ1-treated cells. The protein expression of fibronectin, CCN2, and IL-6 in HTFs treated with 0.023% and 0.046% atelocollagen significantly decreased. The immunofluorescence microscopy of α-SMA and ZO-1 showed results similar to those of the Western blot. In the wound-scratch assays, cell migration was significantly attenuated in HTFs treated with 0.005% atelocollagen. Atelocollagen at 0.005, 0.011, and 0.023% significantly inhibited the gel contraction induced by TGFβ1 at both 24 h and 48 h. The increase in pERK/tERK and pSmad3/tSmad3 protein expression ratios in TGFβ1-treated HTFs significantly decreased after treatment with 0.023 and 0.046% atelocollagen.

CONCLUSION

Since atelocollagen gel effectively suppresses the proliferation of HTFs in TGFβ1-induced transdifferentiation, it may be a potential therapeutic agent in glaucoma surgery.

COMPARISON OF RETROBULBAR, SUB-TENON ANESTHESIA AND MEDIAL CANTHUS EPISCLERAL ANESTHESIA FOR 25-GAUGE POSTERIOR VITRECTOMY

PURPOSE

The aim of the study is to compare the efficacy, safety, and globe akinesia between retrobulbar anesthesia, sub-Tenon anesthesia, and medial canthus episcleral anesthesia for 25-gauge posterior vitrectomy.

METHODS

A total of 340 25-gauge vitrectomy data sheets were retrospectively collected between November 2017 and June 2019. Ninety patients were included in the study. These patients were matched by sex and age to receive retrobulbar anesthesia (group 1, n = 30), sub-Tenon anesthesia (group 2, n = 30), and medial canthus episcleral anesthesia (group 3, n = 30). Globe akinesia was recorded after the injection of anesthetic at 2, 5, and 10 minute time intervals. Patients were asked to rate the pain during administration of anesthesia, during surgery, and postoperatively using the visual analog pain scale.

RESULTS

For a perfect block, at 10 minutes, retrobulbar outperformed both sub-Tenon and medial canthus episcleral anesthesia which seemed quite similar. During administration, the three techniques did not show statistically different effects on pain. Regarding perioperative pain, retrobulbar outperformed medial canthus episcleral anesthesia.

CONCLUSION

All three techniques allowed for safe surgery. Retrobulbar obtained the best results, although sub-Tenon proved to be a valid alternative. Medial canthus episcleral anesthesia obtained mostly good and fair blocks and acceptable pain levels during surgery. Further studies should investigate whether optimal anesthetic efficacy can be obtained with sub-Tenon and medial canthus episcleral techniques when higher volumes are used.

Anti-fibrotic effects of rosmarinic acid on Tenon's capsule fibroblasts stimulated with TGF-β: therapeutic potential in ocular surgery

PURPOSE

Collagen deposition and myofibroblast differentiation are critical factors related to excessive scarring in ocular surgeries. This study evaluated the anti-fibrotic activity of rosmarinic acid on rabbit Tenon's capsule fibroblasts stimulated with transforming growth factor- β2.

METHODS

Primary cultures of rabbit Tenon's capsule fibroblasts were treated with various concentrations of rosmarinic acid for 12 h, in the presence and absence of transforming growth factor-β2. After 48 h, the proliferation index of rabbit Tenon's capsule fibroblasts and the differentiation of myofibroblasts were investigated through immunofluorescence staining for proliferating cell nuclear antigen and alpha smooth muscle actin. An automated cell counter and colorimetric metabolic activity assay were used to evaluate cell number and viability. Collagen expression and production were determined by quantitative real-time polymerase chain reaction and hydroxyproline assay, respectively.

RESULTS

Unstimulated rabbit Tenon's capsule fibroblasts treated with any concentration of rosmarinic acid exhibited diminished collagen expression (p<0.01) but showed no differences in proliferation index. Transforming growth factor-β2 exposure induced myofibroblast differentiation and increased collagen production. Exposure to rosmarinic acid at 1.0 and 3.0 µM concentrations reduced the proliferation index (p<0.02), as well as the collagen expression and hydroxyproline content (p<0.05). Exposure to 3.0 µM rosmarinic acid reduced viability (p=0.035) in unstimulated rabbit Tenon's capsule fibroblasts and cell numbers (p=0.001) in both stimulated and unstimulated rabbit Tenon's capsule fibroblast cultures.

CONCLUSIONS

Exposure to 1.0 µM rosmarinic acid was noncytotoxic and led to reduced collagen expression and proliferation of stimulated rabbit Tenon's capsule fibroblasts. These findings suggest that rosmarinic acid is a relatively non-injurious anti-fibrotic compound to rabbit Tenon's capsule fibroblasts, with potential application as an adjunctive agent in ocular procedures, particularly in glaucoma surgeries.

Comparison of the Efficacy of Sub-Tenon versus Intravitreal Triamcinolone Acetonide Injection during Cataract Surgery for Diabetic Macular Edema

PURPOSE

We compared the efficacy of sub-Tenon triamcinolone acetonide (STTA) to intravitreal triamcinolone aceto-nide (IVTA) injections during cataract surgery (CS) for patients with diabetic macular edema (DME).

METHODS

The medical records of 33 eyes (26 patients) with DME which had undergone CS with STTA were compared to those of 34 eyes (27 patients) with DME which had undergone CS with IVTA. Central foveal thickness and best-corrected visual acuity (BCVA) were measured at the baseline and 1, 3, and 6 months after the surgery.

RESULTS

The BCVAs after STTA and IVTA were significantly improved at 3 and 6 months. Thirteen eyes in the IVTA group and 21 eyes in the STTA group required other therapies (p < 0.05). One case developed intraocular pressure elevation after IVTA and underwent selective la ser trabeculoplasty.

CONCLUSIONS

Ophthalmologists should consider the merits and demerits of IVTA and STTA for DME treatment after CS.

Anaesthesia in various anterior segment complications of sub-Tenon surgeries

OBJECTIVE

The sub-Tenon's space is a potential space between the capsule and the sclera. This study evaluated complications from sub-Tenon's anaesthesia in different corneal and anterior chamber ophthalmic surgical procedures.

METHODS

The prospective cross-sectional study was carried out at the Baqai Medical University, Karachi, from March 2010 to August 2011, and comprised 149 patients for various minor and major intraocular surgeries. All the patients were operated under sub-Tenon's anaesthesia, administered in the inferio-nasal quadrant with a 19G cannula.Their complications were noted on a specific proforma. Data was analysed for frequencies of complications. SPSS 13 was used for statistical analysis.

RESULTS

There were 82 (55%) males and 67 (45%) females who underwent surgery. There were 89 (59.7%) right eyes and 60 (40%) left eyes. The commonest surgery was phaco-emulsification (n = 79; 53%), followed by extracapsular cataract extraction with intraocular lens implantation (n = 33; 22.1%). Subconjuctival haemorrhage (n = 75; 50.3%) was the commonest complication, and the least common was pain during injection (n = 9; 6%).

CONCLUSION

There was no incidence of life-threatening or sight-threatening complications. The procedure was almost pain free and can be simply, safely and effectively given by the beginners with due precautions.

[Serum antiretinal antibodies (ARA) in patients with exudative age-related macular degeneration (AMD) treated with transpupillary thermotherapy (TTT) alone and with transpupillary thermotherapy (TTT) combined with injection of triamcinolone acetonide (sTTA) under posterior Tenon's capsule]

PURPOSE

To assess serum level changes of antiretinal antibodies (ARA) in patients with exudative age-related macular degeneration (AMD), treated with transpupillary thermotherapy (TTT) alone and with TTT combined with injection of triamcinolone acetonide (sTTA) under posterior Tenon's capsule and to compare the efficacy of TTT and TTT+sTTA. The purpose of the study was also to estimate if serum ARA may act as the biomarker of AMD.

MATERIAL AND METHODS

This prospective study comprised 46 patients (46 eyes) with exudative AMD. Patients were assigned into: group I (n = 24) received TTT alone and group II (n = 20) received TTT with sTTA. Follow-up was at 3, 6, 9 and 12 months, when best-corrected visual acuity (BCVA), Amsler grid-test, intraocular pressure (IOP), fluorescein angiography (FA) and central retinal thickness (CRT) by optical coherence tomography (OCT) were assessed. In all patients serum ARA was determined using indirect immunofluorescence (IIF) method on normal monkey retina as antigens substrate and FITC--labelled goat's anti-human IgA, G, M serum as the secondary antibody.

RESULTS

Baseline serum ARA titres in group I ranged from 1: 40 to 1: 5120 and in group II--1: 40 to 1: 1280 (p = 0.1). In control group serum ARA was present in 46.4% of sera in titres from 1: 10 to 1: 40. These differences were statistcally significant (p < 0.001). Nine fluorescence patterns of ARA were detected by IIF method in both groups of AMD patients, while control sera showed only three types of reaction. Statistically significant correlation was found between CNV size, CRT and serum ARA titres in both groups of patients (p < 0.01). In a follow-up period decreasing serum ARA titres were noted, specially for subjects treated with combined therapy, however it was not statistically significant at 3, 6 and 9 months while achieved significance (p < 0.01) at month 12. BCVA improvement or stabilization was observed in 64% of eyes in group I and in 75%--in group II (p = 0.1). No leakage on FA was found in 66.7% and 70% of cases, in group I and II, respectively (p = 0.01). CRT reduction was observed in 50% (group I) and in 70% (group II) of eyes (p = 0.01) at month 12.

CONCLUSIONS

Our preliminary observations indicate that serum ARA changes may reflect the activity of CNV in a course of AMD and may act as the biomarker of treatment efficacy. The use of sTTA in conjunction with TTT for CNV in AMD showed a tendency towards lower serum ARA titres and better functional results after treatment as compared with eyes treated with TTT alone.

Transpupillary thermotherapy (TTT) with injections of triamcinolone acetonide under posterior Tenon's capsule in the treatment of exudative age-related macular degeneration (AMD)

PURPOSE

To evaluate the efficacy of transpupillary thermotherapy (TTT) with injection of triamcinolone acetonide under posterior Tenon's capsule for exudative age-related macular degeneration (AMD).

MATERIAL AND METHODS

The study included two groups of patients with subfoveal choroidal neovascularization (CNV) due to AMD: group I (n = 20) received TTT alone and group II (n = 20) received TTT combined with sub-Tenon's injection of 40 mg of triamcinolone acetonide (TA). The best corrected visual acuity (BCVA), Amsler grid test, contrast sensitivity and fluorescein angiography (FA) at 10-12 weeks after treatment were compared to the baseline values.

RESULTS

The average age for group I was 72.3 years and for group II 74.6 years. Occult CNV was present in 54% and 43%; predominately classic in 22% and 25%; and minimally classic in 24% and 32% of group I and II respectively. The baseline BCVA in group I ranged from 0.02 to 0.2 and in group II--from 0.03 to 0.1. BCVA was maintained or improved in 7 patients (35%) in group I and in 12 eyes (60%) in group II. The deterioration of the BCVA was noted in 13 patients (65%) and in 8 patients (40%) in group I and II respectively. In 65% of eyes in group I and in 83% in group II the improvement in contrast sensitivity was observed. The rate of color vision improvement was 62% and 91%. Regression of metamorphopsia and/or scotoma in central visual field was observed in 11 cases (55%) and in 14 cases (70%) in group I and II respectively. FA showed complete or partial closure of CNV in 9 and 14 eyes (p = 0.02) in group I and II, respectively.

CONCLUSIONS

The results of our preliminary study indicate that TTT combined with sub-Tenon's injections of triamcinolone acetonide may be a beneficial treatment modality with tendency to better functional results than TTT alone, in patients with exudative AMD. However for the precise evaluation of efficacy of this therapy a larger group of patients and longer follow-up are necessary.