Recurrent corneal erosions related to an ocular injury 15 years before presentation

Purpose

To report the case of a patient who presented with recurrent corneal erosions caused by an undetected plastic foreign body in the upper eyelid, which had remained asymptomatic for nearly 15 years following an ocular injury.

Observations

A 39-year-old patient presented with recurrent corneal erosions and frontal headaches of unknown aetiology over the preceding eight months. The patient had previously been seen by twelve different ophthalmologists and had been treated over a 6-month period with a bandage contact lens, and therapeutic corneal scraping had been performed twice. However, the corneal erosion had repeatedly reappeared after removal of the bandage contact lens. On clinical examination prior to a planned phototherapeutic keratectomy, we extracted a 1.5 cm plastic foreign body, localised in the subtarsal area of the upper conjunctival fornix. Upon specific questioning, the patient denied any recent trauma, but reported a work-related accident with an accompanying eye injury 15 years before presentation.

Conclusions and importance

Posttraumatic foreign bodies in the eye may remain asymptomatic for prolonged periods before giving rise to clinical signs such as recurrent corneal erosions. Hence, a thorough clinical examination with meticulous eyelid eversion should always be performed in such patients.

Translation of hyaluronic acid–based vitreous substitutes towards current regulations for medical devices

PURPOSE

Hydrogel-based vitreous substitutes have the potential to overcome the limitations of current clinically used endotamponades. With the goal of entering clinical trials, the present study aimed to (I) transfer the material synthesis of hyaluronic acid-based hydrogels into a routine, pharmaceutical-appropriate production and (II) evaluate the properties of the vitreous substitutes in terms of the current regulations for medical devices (MDR/ISO standards).

METHODS

The multistep manufacturing process of the vitreous substitutes, including the modification of hyaluronic acid with glycidyl methacrylate, photocopolymerization with N-vinylpyrrolidone, and successive hydrogel purification, was developed under laboratory conditions, characterized using ¹ H-NMR, FT-IR and UV/Vis spectroscopies and HPLC, and transferred towards a pharmaceutical production environment considering GMP standards. The optical and viscoelastic characteristics of the hyaluronic acid-based hydrogels were compared with those of extracted human vitreous and silicone oil. The effect of the hydrogels on the metabolic activity, proliferation and apoptosis of fibroblast (MRC-5, BJ, L929), retinal pigment epithelial (ARPE-19, hiPSC-derived RPE) and photoreceptor cells (661W) was studied as well as their mucosal tolerance via a HET-CAM assay.

RESULTS

Hyaluronic acid-based hydrogels having a suitable purity, sterility, high transparency (>90%), appropriate refractive index (1.3365) and viscoelasticity (G' > G″) were prepared in a standardized manner under controlled process conditions. The metabolic activity, proliferation and apoptosis of various cell types as well as egg choroid were unaffected by the hyaluronic acid-based vitreous substitutes, demonstrating their biocompatibility.

CONCLUSIONS

The present study demonstrates the successful transferability of the crucial synthesis steps of hyaluronic acid-based hydrogels into a routine, GMP-compliant production process while achieving the optical and viscoelastic properties, biocompatibility and purity required for their clinical use as vitreous substitutes.

Temporary iris-lens diaphragm to assist descemet membrane endothelial keratoplasty in aphakic patients

Purpose

Presenting a simple technique using an inversely implanted contact lens to create a temporary diaphragm to assist DMEK surgery in aphakic, partially aniridic and vitrectomized eyes.

Observations

The postoperative course was without pressure abnormalities and the anterior chamber remained deep. The cornea completely cleared within 3 weeks and remained clear after removal of the contact lens showing a corneal thickness of 544 μm and an intact endothelial cell pattern on endothelial cell microscopy after 3 months.

Conclusion and Importance

The inversely implanted contact lens provides an easily accessible temporary diaphragm, making DMEK surgery a safer procedure even in complex eyes without an adequate posterior barrier.

[Modifications of canaloplasty : Strong pressure-lowering effect with a low risk profile]

Trabeculectomy still achieves the strongest intraocular pressure (IOP) reduction of all glaucoma surgical techniques, but with the drawback of a significant risk profile. Against this background, canaloplasty has established itself as a much gentler alternative which achieves sufficient IOP reduction and enables a significant reduction in postoperative glaucoma medication. However, approximately half of patients are not completely medication free. In response, a number of modifications have been developed with the goal of further enhancing the IOP-lowering effect of canaloplasty, but without the risk of serious complications. By combining canaloplasty with the newly developed suprachoroidal drainage, a uveoscleral drainage is created in addition to the trabecular outflow improvement, which seems to have an additive effect. Thus, for the first time, an IOP-lowering effect comparable to successful trabeculectomy can be achieved. Numerous other modifications with implants also enhance the potential of canaloplasty or offer other additional benefits such as the possibility of telemetric IOP self-measurement by the patient. The additional creation of a subconjunctival drainage with or without use of cytostatic drugs also seems promising. Ab interno procedures, on the other hand, have limited pressure-lowering potential but may provide some additional benefit in mild glaucoma and in the setting of cataract surgery.

Vitreous Substitutes as Drug Release Systems

Vitreous substitutes are traditionally used to stabilize the retina after vitrectomy. In recent years, various approaches have been developed for using the vitreous substitute not only as a tamponade but also as a drug release system to tackle ocular diseases. This review provides an overview of the requirements for vitreous substitutes and discusses the current clinically applied as well as novel polymer-based vitreous substitutes as drug delivery systems, including their release mechanisms, efficiencies, challenges, and future perspectives.

Measurement of intraocular temperature in glaucoma: week-day and seasonal fluctuations

PURPOSE

To evaluate long-term intraocular temperature (IOT) variations in eyes with primary open-angle glaucoma (POAG) using an intraocular telemetric sensor.

METHODS

This prospective, open-label, multicentre observational study analysed the IOT variations in 22 eyes of 22 patients with POAG. All enrolled patients underwent implantation of an intraocular pressure (IOP) sensor during cataract surgery. The telemetric system uses a built-in temperature sensor to control measured IOP for temperature. Each time a patient measures their IOP, both the IOP and IOT are recorded in the reader device. Patients were instructed to self-measure their IOP as often as desired, but at least four times daily. Recorded readings were retrieved and analysed using mixed effect models and pairwise comparisons using Bonferroni correction to assess the statistical significance of average IOT variations between each individual weekday and calendar month.

RESULTS

The mean age of patients was 67.8±6.8 years and 36.4% were women. A total of 132 745 readings over 21 102 measurement-days were obtained. On average, IOT was significantly higher on Sundays (34.57°C; 95% CI 34.37 to 34.78) than on any other day of the week (p<0.001). Mean IOT on other weekdays ranged from 34.48°C to 34.51°C. Over the year, IOT followed a clear seasonal pattern, reaching its maximum in July (34.8°C; 95% CI 34.56 to 34.97) and its minimum in January (34.4°C; 95% CI 34.15 to 34.56; p<0.001).

CONCLUSIONS

This study demonstrates the feasibility of continual and long-term measurement of IOT using intraocular sensors. The results show significant short-term and long-term fluctuations of IOT. Research is warranted to understand the impact of IOT variations on IOP, ocular perfusion and glaucoma progression.

The molecular hallmarks of primary and secondary vitreoretinal lymphoma

Vitreoretinal lymphoma (VRL) is a rare subtype of diffuse large B-cell lymphoma (DLBCL) considered a variant of primary central nervous system lymphoma (PCNSL). The diagnosis of VRL requires examination of vitreous fluid, but cytologic differentiation from uveitis remains difficult. Because of its rarity and the difficulty in obtaining diagnostic material, little is known about the genetic profile of VRL. The purpose of our study was to investigate the mutational profile of a large series of primary and secondary VRL. Targeted next-generation sequencing using a custom panel containing the most frequent mutations in PCNSL was performed on 34 vitrectomy samples from 31 patients with VRL and negative controls with uveitis. In a subset of cases, genome-wide copy number alterations (CNAs) were assessed using the OncoScan platform. Mutations in MYD88 (74%), PIM1 (71%), CD79B (55%), IGLL5 (52%), TBL1XR1 (48%), ETV6 (45%), and 9p21/CDKN2A deletions (75%) were the most common alterations, with similar frequencies in primary (n = 16), synchronous (n = 3), or secondary (n = 12) VRL. This mutational spectrum is similar to MYD88mut/CD79Bmut (MCD or cluster 5) DLBCL with activation of Toll-like and B-cell receptor pathways and CDKN2A loss, confirming their close relationship. OncoScan analysis demonstrated a high number of CNAs (mean 18.6 per case). Negative controls lacked mutations or CNAs. Using cell-free DNA of vitreous fluid supernatant, mutations present in cellular DNA were reliably detected in all cases examined. Mutational analysis is a highly sensitive and specific tool for the diagnosis of VRL and can also be applied successfully to cell-free DNA derived from the vitreous.

Erworbene Katarakte

Weitaus seltener und daher weniger bekannt als die altersbedingte Katarakt ist die sekundär erworbene Katarakt, die eine diagnostische und chirurgische Herausforderung darstellen kann. Dieser Beitrag gibt einen Überblick über die häufigsten Subtypen vor allem bei Erwachsenen und beleuchtet die chirurgischen Besonderheiten einschließlich perioperativer Charakteristika.

Erworbene Katarakte

Weitaus seltener und daher weniger bekannt als die altersbedingte Katarakt ist die sekundär erworbene Katarakt, die eine diagnostische und chirurgische Herausforderung darstellen kann. Dieser Beitrag gibt einen Überblick über die häufigsten Subtypen vor allem bei Erwachsenen und beleuchtet die chirurgischen Besonderheiten einschließlich perioperativer Charakteristika.

Influence of the scleral indentation technique on the re-detachment rate following retinal detachment surgery

Purpose

The aim of this study was to determine whether the choice of scleral indentation technique during primary rhegmatogenous retinal detachment surgery has an influence on the risk of re-detachment.

Methods

We included retrospectively 154 eyes with a primary rhegmatogenous retinal detachment treated in the Eye Clinic Sulzbach/Saar Germany, who were operated on by two experienced surgeons using the same basic surgical setup. Surgeon A performed an external 360° indentation, shaved the vitreous base using the light pipe cap, and used the operating microscope (opm) for direct visualization. Surgeon B performed an external 360° indentation, shaved the vitreous base using a simple indentor, and used an endoillumination (light pipe) with the opm and a handheld widefield lens for direct visualization.

Results

Comparing both indentation procedures, 15.66% (13/83) of patients operated on by surgeon A and 9.86% (7/71) of patients operated on by surgeon B had a retinal re-detachment within a follow-up period of 6 months (adj. p = 0.64, two-proportion Z-test).

Conclusion

The rate of retinal re-detachment could be influenced by the indentation technique at the end of surgery favoring external indentation and internal visualization with an endoilluminator (chandelier light). We attribute this to the better visualization of the vitreous base facilitated by endoillumination. However, many variables play a role in the development of retinal re-detachment, requiring further studies with a larger number of patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40942-022-00362-8.

What we already know:

Scleral indentation is widely recognized as an important step in rhegmatogenous retinal detachment surgery via pars-plana vitrectomy.

There are several surgical techniques for scleral indentation, however the procedures are neither standardized, nor have they ever been compared to one another to the best of our knowledge.

What this study adds:

This study shows that the rate of retinal re-detachment could be influenced by the indentation technique at the end of surgery favoring external indentation and internal visualization with an endoilluminator (chandelier light).

We attribute this to the better visualization of the vitreous base facilitated by endoillumination.

REVISED PREDICTIVE BIOMARKER FOR OCRIPLASMIN THERAPY IN VITREOMACULAR TRACTION DISORDERS

PURPOSE

To determine a statistically optimal limit of adhesion size in vitreomacular traction (VMT) syndrome for ocriplasmin treatment.

METHODS

In this retrospective, consecutive, interventional study, we included 106 patients treated with ocriplasmin injection because of VMT between July 2013 and January 2018. A univariate and multivariate risk analysis was performed with grouped factors and continuous factors. We used a receiver operating characteristic curve to measure the prognostic relevance of each continuous factor for therapy success and determined the statistically optimal cutoff value at which specificity and sensitivity are simultaneously maximized.

RESULTS

Among the grouped factors, only a phakic lens status showed a highly significant positive influence on the resolution of the VMT. For the continuous factors, only the adhesion diameter before injection was a good predictor of anatomical success. The statistically optimal threshold value for the adhesion size was calculated to be 480 µm. Eyes below this limit had a 6.84-fold better chance of VMT resolution compared with eyes with a larger adhesion diameter.

CONCLUSION

The threshold value of the VMT diameter for ocriplasmin therapy could be statistically defined as 480 µm and may thus be a new quantitative biomarker to predict treatment success.

Comparative cytotoxic and antiproliferative profile of methotrexate and fluorouracil on different ocular cells

PURPOSE

To analyse the cytotoxic and antiproliferative effect of methotrexate (MTX) and fluorouracil (5-FU) in vitro on fibroblasts, retinal pigment epithelial (RPE) and photoreceptor cells as an adjunct for reducing the incidence of proliferative vitreoretinopathy (PVR) after rhegmatogenous retinal detachment surgery.

METHODS

Methotrexate and 5-FU were dissolved separately in balanced salt solution (BSS) with concentrations ranging from 0-8000 µg/ml and 0-4000 µg/ml, respectively. All solutions were analysed in terms of pH and osmolarity and applied for 1 h to fibroblasts (BJ), RPE (ARPE-19) and photoreceptor (661W) cell lines adherently cultivated in 96-well cell culture plates (10 000 cells/well). 24 h after incubation, the proliferative (BrdU), metabolic (CellTiter-Glo) and apoptotic (Caspase 3/7) activity of the cells were examined in vitro.

RESULTS

5-FU had an antiproliferative effect on BJ and ARPE-19 cells starting from low concentrations (2 µg/ml). However, the viability of 661W cells decreased and apoptosis was induced with increasing 5-FU concentration. In contrast, MTX up to a concentration of 266 µg/ml did neither result in a significant loss of viability nor in increased caspase 3/7 activity of BJ, ARPE-19 and 661W cells and inhibited the proliferation of ARPE-19 already at low concentrations starting from 8 µg/ml.

CONCLUSIONS

Methotrexate dissolved in BSS is biocompatible up to a concentration of 266 µg/ml and may act as an intraoperative rinse solution to inhibit RPE proliferation in PVR-diseased eyes. Contrary, the use of 5-FU within the posterior segment of the eye is limited by its cell-damaging effect on photoreceptor cells.

Clinical results after single asymmetrical shark fin for graft orientation in DMEK

PURPOSE

Evaluating the effect of a single peripheral triangular mark to ensure the correct anterior-posterior graft orientation in DMEK.

METHODS

Retrospective study of patients scheduled for DMEK due to Fuchs endothelial dystrophy and divided into 2 study groups: Group -M (n = 184) had no mark of the EDM (Endothelial Descemet membrane) and group + M (n = 193) had a triangular peripheral mark. Follow-up time was 1 year after surgery.

RESULTS

The postoperative graft turning and Re-DMEK rate could be significantly reduced by the use of a peripheral mark (p = 0.002, p = 0.001, respectively). Re-DMEK due to primary graft failure was significantly associated with prior graft turning (p < 0.001). Both groups showed comparable values for visual acuity, central corneal thickness and endothelial cell count after a follow-up of 1 year.

CONCLUSION

Single peripheral triangular marking is a simple and cost-saving addition to EDM preparation to ensure the correct orientation of the graft intraoperatively and could lead to a significant reduction in graft turning and re-DMEK rate in this study.

Cleavage plane after liquid-bubble preparation of Descemet's membrane

PURPOSE

To investigate the ultrastructure of the cleavage plane of human cornea after liquid-bubble-prepared tissue for Descemet's membrane endothelial keratoplasty (DMEK).

METHODS

Experimental study with scanning electron microscopy (SEM) and block-face SEM of 18 corneal specimens. Fresh human research donor corneoscleral discs (n = 12) were prepared with liquid-bubble technique or examined as untreated controls (n = 3). In addition, Descemet's membrane samples, n = 3, were obtained in DMEK surgery.

RESULTS

The cleavage plane after liquid-bubble Descemet's membrane (DM) preparation was consistently located between interfacial matrix and posterior stromal collagen lamellae, providing a largely smooth surface exposing the amorphous interfacial zone without any significant amounts of adherent stromal remnants. No demarcation of a distinct pre-DM layer could be detected.

CONCLUSION

The DMEK graft preparation performed by liquid-bubble technique showed a smooth cleavage plane and could not reveal any demarcation of a distinct pre-DM layer.

Effectiveness of ocriplasmin in real-world settings: A systematic literature review, meta-analysis, and comparison with randomized trials

Purpose

Effectiveness of ocriplasmin for vitreomacular traction (VMT) varies depending on the presence of common ocular conditions and patient selection criteria. We carried out a systematic literature review and meta‐analysis of ocriplasmin studies conducted in real‐world settings (RWS) and compared outcomes with those from randomized controlled trials (RCTs).

Methods

We included prospective and retrospective studies from RWS documenting effectiveness of ocriplasmin in patients with VMT with or without MH, and RCTs of ocriplasmin versus control. Key end‐points were vitreomacular adhesion resolution (VMAR), nonsurgical MH closure, need for vitrectomy and safety. We conducted meta‐regression on pooled results to evaluate effects of baseline covariates and study design on outcomes.

Results

Thirty RWS (2402 patients) and 5 RCTs (737 patients) were included epiretinal membrane (ERM) and broad VMA were more prevalent in RCTs. Primary VMAR, vitrectomy and MH closure rates were comparable between RWS and RCTs. Rates of nsVMAR were significantly higher in RWS than RCTs (odds ratio 1.66; 95% confidence interval [CI]: 1.18–2.34). nsVMAR rates were inversely associated with ERM prevalence (odds ratio 0.20; 95% CI: 0.08–0.51). Compared with the recent OASIS trial, RWS reported a higher incidence of new/worsening subretinal fluid cases and less photophobia, photopsia, vitreous floaters, electroretinogram abnormalities and MH progression.

Conclusions

Ocriplasmin was significantly more effective in achieving nsVMAR in RWS than in RCTs. Lower ERM prevalence in RWS was the single significant explanatory variable for this difference. Conclusions on ocriplasmin safety in RWS are limited due to inconsistent reporting.

The impact of limbus detection, arcus lipoides and limbal vessels on the primary patency of clear cornea incisions in femtosecond laser-assisted cataract surgery

PURPOSE

To analyse the factors influencing the primary patency of clear corneal incisions in femtosecond laser-assisted cataract surgery (FLACS).

METHODS

In this prospective single-centre study, the graphical user interfaces of 159 patients undergoing femtosecond laser-assisted cataract surgery were documented by video. Subsequently, the quality of limbus detection along with the incidence of vessels and an arcus lipoides were assessed by a grading system and analysed in relation to the primary patency of the incisions. In particular, the differences between a superior and a temporal main incision were analysed.

RESULTS

The designed grading system could be applied in all cases without any problems. Limbus detection was highly inhomogeneous but had no influence on the patency of the incisions (46.3% poor, 18.4% moderate, 35.1% good). The characteristics of the arcus lipoides had little influence on the patency of the main incisions. Pronounced vascular ingrowth caused more tissue bridges but did not reduce the patency of the incisions. Temporal access was generally easier to open than a superior one (97.1% versus 88.9%).

CONCLUSION

We showed a patency rate of superior FLACS incisions of over 97% with the Femto LDV Z8 in our study. Temporal main incision is preferable to superior main incision in more difficult situations. The new grading system is suitable for further studies to provide information on the quality of the incision.

Selective Large-Area Retinal Pigment Epithelial Removal by Microsecond Laser in Preparation for Cell Therapy

Purpose

Cell therapy is a promising treatment for retinal pigment epithelium (RPE)-associated eye diseases such as age-related macular degeneration. Herein, selective microsecond laser irradiation targeting RPE cells was used for minimally invasive, large-area RPE removal in preparation for delivery of retinal cell therapeutics.

Methods

Ten rabbit eyes were exposed to laser pulses 8, 12, 16, and 20 µs in duration (wavelength, 532 nm; top-hat beam profile, 223 × 223 µm²). Post-irradiation retinal changes were assessed with fluorescein angiography (FA), indocyanine green angiography (ICGA), and optical coherence tomography (OCT). RPE viability was evaluated with an angiographic probit model. Following vitrectomy, a subretinal injection of balanced salt solution was performed over a lasered (maximum 13.6 mm2) and untreated control area. Bleb retinal detachment (bRD) morphology was then evaluated by intraoperative OCT.

Results

Within 1 hour after irradiation, laser lesions showed FA and ICGA leakage. OCT revealed that large-area laser damage was limited to the RPE. The angiographic median effective dose irradiation thresholds (ED50) were 45 µJ (90 mJ/cm2) at 8 µs, 52 µJ (104 mJ/cm2) at 12 µs, 59 µJ (118 mJ/cm2) at 16 µs, and 71 µJ (142 mJ/cm2) at 20 µs. Subretinal injection over the lasered area resulted in a controlled, shallow bRD rise, whereas control blebs were convex in shape, with less predictable spread.

Conclusions

Large-area, laser-based removal of host RPE without visible photoreceptor damage is possible and facilitates surgical retinal detachment.

Translational Relevance

Selective microsecond laser-based, large-area RPE removal prior to retinal cell therapy may reduce iatrogenic trauma.