Potential new fluoroquinolone treatments for suspected bacterial keratitis

Topical fluoroquinolones (FQs) are an established treatment for suspected microbial keratitis. An increased FQ resistance in some classes of bacterial pathogens is a concern. Some recently developed FQs have an extended spectrum of activity, making them a suitable alternative for topical ophthalmic use. For example, the new generation FQs, avarofloxacin, delafloxacin, finafloxacin, lascufloxacin, nadifloxacin, levonadifloxacin, nemonoxacin and zabofloxacin have good activity against the common ophthalmic pathogens such as Staphylococcus aureus, Pseudomonas aeruginosa, Streptococcus pneumoniae and several of the Enterobacteriaceae. However, because there are no published ophthalmic break-point concentrations, the susceptibility of an isolated micro-organism to a topical FQ is extrapolated from systemic break-point data and wild type susceptibility. The purpose of this review is to compare the pharmacokinetics and pharmacodynamics of the FQs licensed for topical ophthalmic use with the same parameters for new generation FQs. We performed a literature review of the FQs approved for topical treatment and the new generation FQs licensed to treat systemic infections. We then compared the minimum inhibitory concentrations (MIC) of bacterial isolates and the published concentrations that FQs achieved in the cornea and aqueous. We also considered the potential suitability of new generation FQs for topical use based on their medicinal properties. Notably, we found significant variation in the reported corneal and aqueous FQ concentrations so that reliance on the reported mean concentration may not be appropriate, and the first quartile concentration may be more clinically relevant. The provision of the MIC for the microorganism together with the achieved lower (first) quartile concentration of a FQ in the cornea could inform management decisions such as whether to continue with the prescribed antimicrobial, increase the frequency of application, use a combination of antimicrobials or change treatment.

Blast Wound Dehiscence During Descemet Membrane Endothelial Keratoplasty Rebubbling in a Previous Penetrating Keratoplasty: A Case Report

PURPOSE

The purpose of this study was to describe a rare complication of Descemet membrane endothelial keratoplasty (DMEK) rebubbling.

METHODS

An 86-year-old woman with bilateral penetrating keratoplasty (PK) performed 20 years previously for Fuchs endothelial dystrophy underwent DMEK surgery for endothelial corneal decompensation in the left eye. Surgery was complicated in the postoperative period by repeated DMEK graft detachments requiring rebubbling.

RESULTS

The third rebubbling procedure caused a traumatic PK wound dehiscence at the graft-host junction with full-thickness opening of approximately 180 degrees. PK wound dehiscence was resutured in the theater, DMEK lenticule was removed from the eye, and the full-thickness graft was repeated.

CONCLUSIONS

DMEK graft rebubbling in patients with previous PK may lead to traumatic wound dehiscence. Avoidance of excessive increases in intraocular pressure during the rebubbling procedure should be encouraged to decrease the risk of this rare complication.

Delivering Endothelial Keratoplasty Grafts: Modern Day Transplant Devices

PURPOSE

To summarize the graft loading, transporting and delivery devices used for endothelial keratoplasty (EK).

METHODS

A literature search of electronic databases was performed.

RESULTS

New techniques and devices have been introduced and implemented to prepare, load, transport and transplant the grafts for EK. The advantages are not only limited to the surgical theatre but also widely spread across the eye banking field. Investigation of advanced materials and designs have been rapidly growing with continuous evolution in the field of eye banking and corneal transplantation. Innovative techniques and modern devices have been evaluated to reduce the endothelial cell loss and increase the precision of the transplant in order to benefit both surgeons and the patients.

CONCLUSIONS

It is extremely important to reduce any potential wastage and optimize the use of every available donor cornea due to the limited availability of healthy cadaveric donor corneas required for transplants. As a result, the use of pre-cut and pre-loaded grafts supplied by the eye banks in calibrated devices have been gaining momentum. Innovation in the field of bioengineering for the development of new devices that facilitate excellent clinical outcomes along with reduction in learning curve has shown promising results.

Factors Affecting the Success Rate of Preloaded Descemet Membrane Endothelial Keratoplasty With Endothelium-Inward Technique: A Multicenter Clinical Study

PURPOSE

To evaluate factors affecting the outcomes of preloaded Descemet membrane endothelial keratoplasty (pl-DMEK) with endothelium-inward.

DESIGN

Retrospective clinical case series and a comparative tissue preparation study.

METHODS

Participants: Fifty-five donor tissues for ex vivo study and 147 eyes of 147 patients indicated with Fuchs endothelial dystrophy or pseudophakic bullous keratopathy with or without cataract.

INTERVENTION

Standardized DMEK peeling was performed with 9.5-mm-diameter trephination followed by second trephination for loading the graft (8.0-9.5 mm diameter). The tissues were manually preloaded with endothelium-inward and preserved for 4 days or shipped for transplantation. Live and dead assay and immunostaining was performed on ex vivo tissues. For the clinical study, the tissues were delivered using bimanual pull-through technique followed by air tamponade at all the centers.

MAIN OUTCOME MEASURES

Tissue characteristics, donor and recipient factors, rebubbling rate, endothelial cell loss (ECL), and corrected distance visual acuity (CDVA) at 3, 6, and 12 months.

RESULTS

At day 4, significant cell loss (P = .04) was observed in pl-DMEK with loss of biomarker expression seen in prestripped and pl-DMEK tissues. Rebubbling was observed in 40.24% cases. Average ECL at 3, 6, and 12 months was 45.87%, 40.98%, and 47.54%, respectively. CDVA improved significantly at 3 months postoperation (0.23 ± 0.37 logMAR) (P < .01) compared to the baseline (0.79 ± 0.61 logMAR). A significant association (P < .05) between graft diameter, preservation time, recipient gender, gender mismatch, and recipient age to rebubbling rate was observed.

CONCLUSION

Graft loading to delivery time of pl-DMEK tissues in endothelium-inward fashion must be limited to 4 days after processing. Rebubbling rate and overall surgical outcomes following preloaded DMEK can be multifactorial and center-specific.

Gender Matching Did Not Affect 2-year Rejection or Failure Rates Following DSAEK for Fuchs Endothelial Corneal Dystrophy

PURPOSE

To investigate whether donor to recipient gender or H-Y mismatching was associated with graft rejection or failure following Descemet stripping automated endothelial keratoplasty (DSAEK) in patients with Fuchs endothelial corneal dystrophy (FECD).

DESIGN

Clinical cohort study.

METHODS

This study used a multi-center registry including patients aged >18 years who had undergone their first DSAEK for FECD between January 2008 and March 2018. The impact of donor and recipient gender incompatibility (including H-Y mismatches) on corneal graft rejection and failure was evaluated using Kaplan-Meier curves and univariable and multivariable Cox models.

RESULTS

Outcome data from 4341 eyes (3915 from the UK and 426 from Italy) were analyzed. Graft failure at 2-year follow-up occurred in 477 (11.0%) cases. Graft rejection at 2-year follow-up occurred in 175 cases (4.0%), 58 (1.3%) of whom developed graft failure. There was no significant effect of gender or H-Y mismatching on either rejection (P = .12, P = .06) or failure (P = .28, P = .14), respectively.

CONCLUSIONS

In patients with FECD undergoing DSAEK, no significant influence of gender and or H-Y mismatch on graft rejection or failure was found.

Update on Suture Techniques in Corneal Transplantation: A Systematic Review

Effective suturing remains key to achieving successful outcomes in corneal surgery, especially anterior lamellar keratoplasty and full thickness transplantation. Limitations in the technique may result in complications such as wound leak, infection, or high astigmatism post corneal graft. By using a systematic approach, this study reviews articles and conducts content analysis based on update 2020 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria). The aim of this paper is to summarize the state of the art of corneal suturing techniques for every type of corneal transplant and patient age and also their outcomes regarding astigmatism and complications. Future developments for corneal transplantation will be also discussed. This is important because especially the young surgeon must have knowledge of the implications of every suture performed in order to achieve consistent and predictable post-operative outcomes and also be aware of all the possible complications.

Epithelial Cell-Derived Extracellular Vesicles Trigger the Differentiation of Two Epithelial Cell Lines

Extracellular vesicles (EVs), specifically exosomes, carry a cell-type dependent cargo that is transported to the recipient cell and translated in the presence of a required machinery. Differences in the cargo carried by the corneal and conjunctival-derived EVs could be the agent that triggers the transdifferentiation of these two cell populations. Therefore, this study investigates the role of EVs in triggering the plasticity of corneal and conjunctival epithelial cells and identifies prospective miRNA and genes responsible for maintaining ocular surface homeostasis. The EVs were extracted from the conditioned media (after starving) of corneal epithelial (hTCEpi) and conjunctival (HCjE-Gi) cell lines using ultracentrifugation. HCjE-Gi cells were cultured with hTCEpi-derived EVs and vice-versa. The EVs were characterized as exosomes using Nanosight and Flow cytometry. KRT3 and KRT12 were used as associated corneal markers, whereas KRT7 and KRT13 were used as associated conjunctival markers with ΔNp63 as a differentiation marker. Shift of these markers was an indication of transdifferentiation. The cargo of the extracted exosomes from both the cell types was explored using next-generation sequencing. The hTCEpi-derived EVs induced conjunctival epithelial cells to express the corneal-associated markers KRT3 and KRT12, losing their conjunctival phenotype at both the mRNA and protein level. Simultaneously, HCjE-Gi-derived EVs induced corneal epithelial cells to express the conjunctival associated markers KRT7 and KRT13, losing their corneal phenotype. This process of differentiation was accompanied by an intermediate step of cell de-differentiation showed by up-regulation in the expression of epithelial stem cell marker ΔNp63, also shown on the ex vivo human cadaveric donor corneas. miRNA molecules (total of 11 including precursor and mature) with significant differences in their relative abundance between the two populations (p < 0.05) were found and investigated. miR-9-5p expression was higher in HCjE-Gi cells and HCjE-Gi-derived EVs when compared to hTCEpi cells and hTCEPi-derived EVs (p < 0.001). The results suggest that EVs released by the two cell types have the ability to influence the transdifferentiation of human conjunctival and corneal epithelial cells. miR-9-5p could have a role in stem cell homeostasis and cell differentiation via HES-1 gene.

Eye bank versus surgeon prepared Descemet stripping automated endothelial keratoplasty tissues: Influence on adhesion force in a pilot study

PURPOSE

To evaluate and compare the biomechanical properties of the eye bank-prepared and surgeon prepared Descemet stripping automated endothelial keratoplasty (DSAEK) tissues.

METHODS

In this laboratory study, corneal tissues for research were randomly allocated in the following groups: a) surgeon-cut DSAEK and b) eye bank-prepared (pre-cut and pre-loaded) DSAEK. Endothelial cell loss (ECL), immunostaining for tight junction protein ZO-1, elastic modulus, and adhesion force were investigated.

RESULTS

ECL was not found to be significantly different between surgeon-cut DSAEK (7.8% ±6.5%), pre-cut DSAEK (8.6% ±2.3%), and pre-loaded DSAEK (11.1% ±4.8%) (P = 0.5910). ZO-1 was expressed equally across all groups. Surgeon-cut DSAEK grafts showed a significantly higher elastic modulus compared to pre-cut and pre-loaded DSAEK groups (P = 0.0047 and P < 0.0001, respectively). Adhesion force was significantly greater in the surgeon-cut DSAEK compared to pre-cut (P < 0.0001) or pre-loaded DSAEK groups (P = 0.0101).

CONCLUSION

The laboratory data on the biomechanics of DSAEK grafts suggests that surgeon-cut DSAEK grafts present higher elastic modulus and adhesion force compared to eye bank-prepared DSAEK grafts.

Antimicrobial Nitric Oxide-Releasing Electrospun Dressings for Wound Healing Applications

Nonhealing and chronic wounds represent a major problem for the quality of life of patients and have cost implications for healthcare systems. The pathophysiological mechanisms that prevent wound healing are usually multifactorial and relate to patient overall health and nutrition, vascularity of the wound bed, and coexisting infection/colonization. Bacterial infections are one of the predominant issues that can stall a wound, causing it to become chronic. Successful wound healing often depends on weeks or months of antimicrobial therapy, but this is problematic given the rise in multidrug-resistant bacteria. As such, alternatives to antibiotics are desperately needed to aid the healing of chronic, and even acutely infected wounds. Nitric oxide (NO) kills bacteria through a variety of mechanisms, and thus, bacteria have shown no tendency to develop resistance to NO as a therapeutic agent and therefore can be a good alternative to antibiotic therapy. In this paper, we report on the development of NO-releasing electrospun membranes fabricated from polycaprolactone (PCL)/gelatin blends and optimized to reduce bacterial infection. The NO payload in the membranes was directly related to the number of amines (and hence the amount of gelatin) in the blend. Higher NO payloads corresponded with a higher degree of antimicrobial efficacy. No cytotoxicity was observed for electrospun membranes, and an in vitro wound closure assay demonstrated closure within 16 h. The results presented here clearly indicate that these NO-releasing electrospun membranes hold significant promise as wound dressings due to their antimicrobial activity and biocompatibility.

Amoebicidal Activity of Poly-Epsilon-Lysine Functionalized Hydrogels

Purpose

To determine the amoebicidal activity of functionalized poly-epsilon-lysine hydrogels (pɛK⁺) against Acanthamoeba castellanii.

Methods

A. castellanii trophozoites and cysts were grown in the presence of pɛK solution (0–2.17 mM), pɛK or pɛK⁺ hydrogels, or commercial hydrogel contact lens (CL) for 24 hours or 7 days in PBS or Peptone-Yeast-Glucose (PYG) media (nutrient-deplete or nutrient-replete cultures, respectively). Toxicity was determined using propidium iodide and imaged using fluorescence microscopy. Ex vivo porcine corneas were inoculated with A. castellanii trophozoites ± pɛK, pɛK⁺ hydrogels or commercial hydrogel CL for 7 days. Corneal infection was assessed by periodic acid–Schiff staining and histologic analysis. Regrowth of A. castellanii from hydrogel lenses and corneal discs at 7 days was assessed using microscopy and enumeration.

Results

The toxicity of pɛK⁺ hydrogels resulted in the death of 98.52% or 83.31% of the trophozoites at 24 hours or 7 days, respectively. The toxicity of pɛK⁺ hydrogels resulted in the death of 70.59% or 82.32% of the cysts in PBS at 24 hours or 7 days, respectively. Cysts exposed to pɛK⁺ hydrogels in PYG medium resulted in 75.37% and 87.14% death at 24 hours and 7 days. Ex vivo corneas infected with trophozoites and incubated with pɛK⁺ hydrogels showed the absence of A. castellanii in the stroma, with no regrowth from corneas or pɛK⁺ hydrogel, compared with infected-only corneas and those incubated in presence of commercial hydrogel CL.

Conclusions

pɛK⁺ hydrogels demonstrated pronounced amoebicidal and cysticidal activity against A. castellanii. pɛK⁺ hydrogels have the potential for use as CLs that could minimize the risk of CL-associated Acanthamoeba keratitis.

Anatomical and functional outcomes of pneumatic vitreolysis for treatment of vitreomacular traction with and without macular holes

PURPOSE

To evaluate the outcome of pneumatic vitreolysis (PVL) for vitreomacular traction (VMT) with or without full thickness macular hole (MH) < 400 µm.

METHODS

Forty-seven eyes of 47 patients were included who had undergone PVL for VMT with or without MH. Main outcome measures were release of VMT, MH closure, best-corrected visual acuity (BCVA) and adverse events.

RESULTS

Thirty-three patients had isolated VMT and 14 patients VMT with a MH. Four weeks after PVL, the overall VMT release rate was 35/47 (74.5%): 25/37 (67.6%) in phakic and 10/10 (100%) in pseudophakic eyes (p = 0.03). Four of 14 MH (28.6%) were closed. Twenty-two of 47 (46.8%) eyes required a subsequent PPV: 12/33 (36.4%) in the VMT only group and 10/14 (71.4%) in the VMT with MH group. Mean BCVA improved from 0.48 (± 0.24) to 0.34 (± 0.23) logMAR at 6 months in patients with VMT alone (p < 0.001), and from 0.57 (± 0.27) to 0.41 (± 0.28) logMAR in patients with VMT and MH (p = 0.008). Adverse events included new formation of a large MH in 4/33 (12.1%) eyes, failure of MH closure in 10/14 (71.4%) eyes, progression of mean minimum linear diameter (MLD) MH size from baseline 139 (± 67) to 396 (± 130) µm (p < 0.001) and development of a retinal detachment in 4/47 (8.5%) eyes.

CONCLUSION

While PVL leads to a high VMT release rate particularly in pseudophakic eyes, it is associated with a relatively high incidence of MH formation, MH size progression and retinal detachment.

Risk factors for corneal epithelial wound healing: Can sex play a role?

PURPOSE

To determine if sex is associated with corneal epithelial wound healing time in patients with persistent corneal epithelial defects (PCEDs).

METHODS

Retrospective case series on patients with PCED from November 2014 to January 2019. Records of 127 patients with diagnosis of PCED were reviewed. Patients with an epithelial defect that lasted more than two weeks in the absence of an active corneal infection were included. Main outcome was corneal epithelial wound healing time.

RESULTS

55 patients (29 males) with a mean age of 65.3 ± 16.5 years were included. No difference was found between female and male patients in terms of risk factors, age, treatment strategies or intervals between visits (median of 15 days in females and 12 days in males; p = 0.24). Median duration of the PCED was 51 days (IQR 32-130), with a median number of 5 clinical visits (IQR 4-8). Female patients had significantly longer healing times (p = 0.004) and a corresponding increase in the number of clinical visits (median of 7 visits vs. 5 clinical visits in males, p = 0.012).

CONCLUSION

Results from this study suggest female patients with PCED might have a longer corneal epithelial wound healing duration and may therefore require earlier intervention.

Indocyanine Green Angiographic Assessment of Conjunctival Melanocytic Disorders

PURPOSE

To investigate whether transvascular indocyanine green (ICG) dye leakage is associated with conjunctival malignancy.

METHODS

This is a prospective interventional study. Patients presenting with circumscribed conjunctival melanocytic disorders (CMDs) were included and examined using color photography, anterior segment optical coherence tomography to measure lesion size, and fluorescein and ICG angiography to measure vascular pattern and leakage. Time to vascular leakage was measured by 2 independent observers. Lesions were characterized as benign or malignant based on histopathological features.

RESULTS

Thirty patients with CMD were included: 22 lesions were benign (conjunctival nevus, n = 20; conjunctival melanocytic intraepithelial neoplasia without atypia, n = 2) and 8 were malignant (in situ conjunctival melanoma n = 2; invasive conjunctival melanoma, n = 6). Malignant lesions had larger mean maximal diameters (11.0 ± 4.5 vs. 4.2 ± 2.5 mm, P = 0.003) and more frequently showed intrinsic tumor vasculature (8 of 8 vs. 10 of 22, P = 0.007). The mean time to ICG leakage was 350.9 ± 165.9 seconds in benign and 59.6 ± 22.1 seconds (P = 0.002) in malignant lesions and was inversely correlated with lesion size and thickness.

CONCLUSIONS

Time to angiographic ICG dye leakage is significantly shorter in malignant versus benign CMD.

Defining a Cutoff for Progression of Macular Holes

Purpose

The purpose of this study was to determine a cutoff for progression of idiopathic full-thickness macular hole (MH) size.

Methods

Retrospective analysis of consecutive patients waiting 4 weeks for MH surgery. Two observers performed 3 repeat sets of MH size measurements on optical coherence tomography (OCT) high-density radial scans taken at first presentation and 4 weeks later before surgery. Primary outcome was the definition of a cutoff for true enlargement of MH size versus measurement error. Secondary outcomes were risk factors for change in minimum linear diameter (MLD) size and best-corrected visual acuity (BCVA).

Results

Fifty-one patients were included with a mean MH size of 334 µm (±179 µm; range 39 to 793 µm). The cutoff for an increase in MLD size calculated as the outer confidence limit for the 99.73% limits of agreement was 31 µm. This was independent of MH size. Using this cutoff, MLD size increased in 9/34 (26.5%) of patients without and in 14 of 17 (82.4%) of patients with vitreomacular traction (VMT; P < 0.001). Mean BCVA deteriorated in patients in whom the MH had progressed from 0.62 (±0.23) logMAR to 0.82 (±0.29; P < 0.001), whereas there was no significant change in BCVA in patients without MH progression (P = 0.25). In 31% (16/51) of patients, classification of their MHs (small ≤250 µm, medium 251–400 µm, and large >400 µm) changed over the 4-week period.

Conclusions

Using a cutoff discriminates change from measurement error. A significant proportion of MHs progressed by 4 weeks, particularly in the presence of VMT.

Translational Relevance

The established cutoff enables clinicians to differentiate true MH enlargement from measurement error.

Tomographic and aberrometric assessment of first-time diagnosed paediatric keratoconus based on age ranges: a multicentre study

PURPOSE

To describe paediatric keratoconus (KC) patients by tomographic and aberrometric characteristics at first diagnosis, in a multicentre study.

METHODS

We included 278 eyes from 139 paediatric patients, with a first tomographic diagnosis (Pentacam^® ) of KC prior to 18 years old. KC classification was based on the KC Index (≥ 1.07) and Topographic Keratoconus Classification (TKC ≥ 1). Patients were divided based on age ranges (14 and under and over 14 years) and gender. Statistical analysis was performed with SPSS statistics 25.0. ANOVA factor was carried out comparing to compare groups.

RESULTS

278 eyes were screened, and 230 eyes were diagnosed with paediatric KC. Mean age was 15.48 ± 2.33 (6 to 18) years. We found differences in terms of TKC (2.08 ± 0.89 and 2.38 ± 0.82, p < 0.05) and spherical aberration (-0.71 ± 0.97 and -1.07 ± 1.36, p < 0.05) among the 14 years old or under and above 14 years old groups, respectively. Overall, female paediatric KC patients presented a more severe TKC, Belin Ambrosio Display, maximum keratometry, asphericity and primary and secondary coma aberrations compared to male KC patients. We observed a correlation between CDVA and asphericity (r = 0.71, p < 0.01), as well as between CDVA and spherical aberration (r = 0.69, p < 0.01).

CONCLUSION

Our findings revealed that the debut of KC is usually in a moderate to advanced stage in the paediatric population at first diagnosis, particularly in female patients. Corneal tomography should be systematically performed in children with recent onset of corneal astigmatism.

Cost analysis of eye bank versus surgeon prepared endothelial grafts

Background

Selective lamellar corneal transplantation (keratoplasty) has overtaken full thickness penetrating keratoplasty as the graft choice for endothelial failure. Even more recently eye bank prepared tissues are becoming increasing popular as a way to reduce the risks of tissue loss and stress during endothelial keratoplasty preparation in the surgical theatre. This study compares costs between surgeon and eye bank prepared tissues for Descemet’s stripping automated endothelial keratoplasty (DSAEK) and Descemet’s membrane endothelial keratoplasty (DMEK).

Methods

Retrospective study conducted at the Royal Liverpool University Hospital including endothelial keratoplasties with a minimum of 6 months follow-up time. Cost analysis included surgical expenses, tissue acquisition fees, cost of patient’s ward admission and out-patient expenses, including cost of re-bubbling procedures, costs of visits, anterior segment imaging and optometrist visits within the first 6 months follow-up.

Results

Ninety-eight eyes of 98 patients were included in the study of which 42 underwent DSAEK surgery and 56 DMEK surgery. Cost analysis of surgical expenses in the DSAEK group showed a significant difference between using surgeon prepared and eye bank prepared tissue (£3866 ± 296 and £4389 ± 360, respectively; p < 0.01) and the same was found in the DMEK group (£3682 ± 167 and £4162 ± 167 for surgeon prepared and eye bank prepared tissues, respectively; p < 0.01). Cost of out-patient visits did not differ significantly in either group.

Conclusions

At the Royal Liverpool University Hospital, eye bank prepared tissues had higher surgical expenses compared to those prepared by the surgeon, while the post-operative care expenses were similar between the two groups.

Repeatability and Reproducibility of Macular Hole Size Measurements Using Optical Coherence Tomography

The purpose of this study was to assess the repeatability and reproducibility of measuring the minimum linear diameter (MLD) of macular holes (MHs) using horizontal linear and radial scan modes in optical coherence tomography (OCT). Patients with concurrent sets of radial and horizontal linear OCT volume scans were included. The MLD was measured twice in both scan modes by six raters of three different experience levels (groups). Outcome measures were the reliability and repeatability of MLD measurements. Fifty patients were included. Mean MLD was 317.21(±170.63) µm in horizontal linear and 364.52 (±161.71) µm in radial mode, a difference of 47.31 (±26.48) µm (p < 0.001). In the radial scan mode, MLD was identified within 15° of the horizontal meridian in 27% and within 15° of the vertical meridian in 26.7%, with the remainder (46.3%) in oblique meridians. The intra-group coefficients of repeatability (CR) for horizontal linear mode were 23 µm, 33 µm and 45 µm, and for radial mode 25 µm, 44 µm and 57 µm for groups 1, 2 and 3, respectively. The inter-group CR, taking group 1 as reference standard for groups 2 and 3, were 74 µm and 71 µm for the linear mode, and 62 µm and 78 µm for radial mode. The radial mode provides good repeatability and reliability for measurement of MLD. In a majority of cases the MLD does not lie in the horizontal meridian and would be underestimated using a horizontal OCT mode.

Predictive Association of Pre-Operative Defect Areas in the Outer Retinal Layers With Visual Acuity in Macular Hole Surgery

Purpose

The purpose of this study was to develop methods to model the external limiting membrane (ELM) and ellipsoid zone (EZ) within the elevated cuff surrounding a macular hole (MH) to determine if the predicted size of the defect in these layers after virtual flattening was associated with the actual postoperative defect and best-corrected visual acuity (BCVA).

Methods

Patients were included who had undergone successful MH surgery. The defects in the ELM and EZ after virtual flattening were modeled using in-house software. Main outcomes were postoperative defects in ELM and EZ at 2 months and BCVA at 12 months.

Results

Fifty-eight patients were included. BCVA improved from 0.87 (0.31) logMAR pre-operatively to 0.26 (0.21) at 12 months (P < 0.001). For both the ELM and EZ, the predicted virtually flattened pre-operative defects were associated with the actual postoperative defects at 2 months (R2 = 0.33, P < 0.01 and R2 = 0.50, P < 0.01, respectively). There was a significant association of BCVA at 12 months (adjusted R2 = 0.85) with the pre-operative modeled area of the defect in the ELM (P < 0.01) and to a lesser extent with the defect in the EZ (P < 0.01) and base of the MH (P < 0.01).

Conclusions

Virtually flattening of the pre-operative defect in the ELM provides important predictive information of visual acuity. Incorporation of tools into commercially available optical coherence tomography (OCT) devices to facilitate such measurements would provide the clinician with important prognostic information.

Translational Relevance

We have developed methodology that can potentially be used to predict the postoperative state of the outer retinal layers and the associated visual outcome in patients undergoing surgery for MH.

Biological tissues and components, and synthetic substrates for conjunctival cell transplantation

The conjunctiva is the largest component of the ocular surface. It can be damaged by various pathological processes leading to scarring, loss of tissue and dysfunction. Depending on the amount of damage, restoration of function may require a conjunctival graft. Numerous studies have investigated biological and synthetic substrates in the search for optimal conditions for the ex vivo culture of conjunctival epithelial cells that can be used as tissue grafts for transplantation. These substrates have advantages and disadvantages that are specific to the characteristics of each material; the development of an improved material remains a priority. This review is the second of a two-part review in The Ocular Surface. In the first review, the structure and function of the conjunctiva was evaluated with a focus on the extracellular matrix and the basement membrane, and biological and mechanical characteristics of the ideal substrate with recommendations for further studies. In this review the types of biological and synthetic substrates used for conjunctival transplantation are discussed including substrates based on the extracellular matrix. .

Bilateral Keratoconus Progression: Immediate Versus Delayed Sequential Bilateral Corneal Cross-linking

PURPOSE

To compare immediate sequential bilateral corneal cross-linking (CXL), wherein both eyes are treated on the same day, to delayed sequential bilateral CXL, where each eye is treated on different days for bilateral progressive keratoconus.

METHODS

This was a retrospective case note review of all patients who underwent sequential CXL or delayed CXL for keratoconus at Royal Liverpool University Hospital, United Kingdom. Parameters assessed were the change in maximum keratometry and minimum central corneal thickness on corneal tomography scan, corrected distance visual acuity, and cost estimates of treatment.

RESULTS

A total of 38 patients (31 men and 7 women) with keratoconus with a mean age of 25.3 ± 7.0 years were included. Twenty patients received sequential CXL and 18 received delayed CXL treatment. In both the sequential CXL and delayed CXL groups, the treated eye(s) showed no evidence of progression after the corneal CXL treatment at last follow-up visit after 358 ± 158 days for sequential CXL and 451 ± 205 days for delayed CXL. There were no complications from the treatment in either group. In the delayed CXL group, the mean time interval between the two CXL procedures was 146 ± 129 days. Five of 18 patients (27%) showed progression of keratoconus in their second eye during the waiting time. Economical evaluation showed that four visits were saved for each sequential CXL treatment compared to delayed CXL.

CONCLUSIONS

Delayed CXL carries a risk of progression in the second eye and is associated with a higher economic burden. [J Refract Surg. 2020;36(8):552-556.].

Imaging of vascular abnormalities in ocular surface disease

The vascular system of the ocular surface plays a central role in infectious, autoimmune, inflammatory, traumatic and neoplastic diseases. The development, application, and monitoring of treatments for vascular abnormalities depends on the in vivo analysis of the ocular surface vasculature. Until recently, ocular surface vascular imaging was confined to biomicroscopic and color photographic assessment, both limited by poor reproducibility and the inability to image lymphatic vasculature in vivo. The evolvement and clinical implementation of innovative imaging modalities including confocal microscopy, intravenous, and optical coherence tomography-based angiography now allows standardized quantitative and functional vascular assessment with potential applicability to automated analysis algorithms and diagnostics.

Rebubbling rate in preloaded versus surgeon prepared DSAEK

PURPOSE

To compare the clinical outcomes of eye bank preloaded Descemet stripping automated endothelial keratoplasty (DSAEK) grafts and surgeon prepared.

METHODS

In this retrospective study, the data were obtained from two groups (a) surgeon cut DSAEK where tissue was prepared by the surgeon immediately before surgery, and (b) preloaded DSAEK tissue shipped to the surgeon after preparation by the eye bank. Standard DSAEK preparations using Moria microkeratome with single pass method were performed. For the tissues prepared by the eye banks, they were preloaded in an iGlide device and shipped in transport media. Standard DSAEK surgery using bimanual pull-through technique was performed for all the grafts. Air was used as a tamponade. Main outcome measures included best corrected visual acuity (BCVA) and rebubbling rate.

RESULT

Out of 107 eyes of 101 patients that underwent DSAEK surgery, 33 tissues were prepared by the surgeon (sc-DSAEK), while 74 were prepared by the eye bank (pl-DSAEK). sc-DSAEK showed a rebubbling rate of 9.1%, compared to the 16.2% for the preloaded DSAEK (p = 0.11). There was no statistical difference in postoperative BCVA between the two groups. Logistic regression analysis showed no association between detachment rate and cataract surgery, graft preparation method, graft diameter and reason for graft.

CONCLUSION

Preloaded grafts have similar rebubbling rate and visual acuity achieved compared with surgeon prepared grafts.

Cediranib in addition to chemotherapy for women with relapsed platinum-sensitive ovarian cancer (ICON6): overall survival results of a phase III randomised trial

BACKGROUND

Cediranib, an oral anti-angiogenic VEGFR 1-3 inhibitor, was studied at a daily dose of 20 mg in combination with platinum-based chemotherapy and as maintenance in a randomised trial in patients with first relapse of 'platinum-sensitive' ovarian cancer and has been shown to improve progression-free survival (PFS).

PATIENTS AND METHODS

ICON6 (NCT00532194) was an international three-arm, double-blind, placebo-controlled randomised trial. Between December 2007 and December 2011, 456 women were randomised, using stratification, to receive either chemotherapy with placebo throughout (arm A, reference); chemotherapy with concurrent cediranib, followed by maintenance placebo (arm B, concurrent); or chemotherapy with concurrent cediranib, followed by maintenance cediranib (arm C, maintenance). Due to an enforced redesign of the trial in September 2011, the primary endpoint became PFS between arms A and C which we have previously published, and the overall survival (OS) was defined as a secondary endpoint, which is reported here.

RESULTS

After a median follow-up of 25.6 months, strong evidence of an effect of concurrent plus maintenance cediranib on PFS was observed [hazard ratio (HR) 0.56, 95% confidence interval (CI) 0.44-0.72, P < 0.0001]. In this final update of the survival analysis, 90% of patients have died. There was a 7.4-month difference in median survival and an HR of 0.86 (95% CI: 0.67-1.11, P = 0.24) in favour of arm C. There was strong evidence of a departure from the assumption of non-proportionality using the Grambsch-Therneau test (P = 0.0031), making the HR difficult to interpret. Consequently, the restricted mean survival time (RMST) was used and the estimated difference over 6 years by the RMST was 4.8 months (95% CI: -0.09 to 9.74 months).

CONCLUSIONS

Although a statistically significant difference in time to progression was seen, the enforced curtailment in recruitment meant that the secondary analysis of OS was underpowered. The relative reduction in the risk of death of 14% risk of death was not conventionally statistically significant, but this improvement and the increase in the mean survival time in this analysis suggest that cediranib may have worthwhile activity in the treatment of recurrent ovarian cancer and that further research should be undertaken.