[Surgical technique of keratoplasty with simultaneous implantation of a continuous ring or ring segment into the graft]

The article presents the surgical technique of penetrating keratoplasty (PK) and deep anterior lamellar keratoplasty (DALK) with femtosecond-laser assistance involving simultaneous implantation of an intracorneal continuous ring (ICCR) or an intracorneal ring segment (ICRS) into the graft. Surgical technique no. 1 - keratoplasty with simultaneous implantation of ICRS. Intrastromal circular tunnel is formed in the central zone of donor cornea using femtosecond laser. Then penetrating trepanation 8.1 mm in diameter is performed symmetrically to the formed tunnel. After preparing penetrating or lamellar recipient bed, suture fixation is placed in the corneal transplant, then the ICRS is implanted into the graft. Surgical technique no. 2 - keratoplasty with simultaneous implantation of ICCR. The donor cornea is dissected from periphery to center using femtosecond laser. Central zone remains untouched. A large diameter full-thickness trepanation is performed and the donor cornea is divided into the anterior and posterior layers. The ICCR is put on the donor cornea while holding the posterior layer with forceps. Penetrating or lamellar recipient bed is prepared, then the corneal graft is fixed with sutures. Transparent corneal graft acceptance does not guarantee high visual acuity due to post-keratoplasty astigmatism. Surgical correction of astigmatism is performed in the long term post-operatively and isn't effective enough. We proposed this new surgical technique of keratoplasty with simultaneous implantation of ICCR and ICRS into the graft as close as possible to the visual axis of the eye, which can help make the postoperative astigmatism minimal both immediately after surgery and in the long term. The study proposes a new approach to intraoperative prevention of post-keratoplasty astigmatism. The technique is simple, safe and effective. Analysis of long-term outcomes is required before recommending this method for widespread use in clinical practice.

Outcomes of Penetrating Keratoplasty After Open Globe Injury

PURPOSE

The purpose of this study was to investigate the clinical features, surgical outcomes, and prognostic factors of penetrating keratoplasty (PKP) after open globe injury (OGI).

METHODS

A retrospective review of all patients treated for OGI between January 2000 and July 2017 was conducted. Demographic, preoperative, perioperative, and postoperative data were collected for those who underwent PKP after OGI. The predictive value of each preoperative variable on graft failure was assessed using univariate and multivariable Cox proportional hazards models, and the predictive value of variables on post-PKP visual outcome was assessed using both univariate and multivariable logistic regression models. All eyes that underwent PKP after OGI were included unless they had less than 365 days of follow-up.

RESULTS

Forty-six eyes that underwent PKP met inclusion criteria. The median age was 46 years (interquartile range = 23.00-61.25), median follow-up was 78.5 months (interquartile range = 38.63-122.02), and 37 of 46 subjects (80.4%) were male. The observed 1- and 5-year graft survival estimates were 80.4% and 41.7%, respectively. Factors statistically associated with graft failure in multivariable analyses were rejection episode, hazard ratio (HR) = 3.29; retinal detachment (RD), HR = 3.47; and endophthalmitis, HR = 6.27. Fifteen of 42 eyes (35.7%) regained ambulatory vision (20/200 or better). The strongest predictors of vision worse than 20/200 at the last follow-up were RD, odds ratio (OR) = 43.88; graft rejection, OR = 12.42; and injury outside the workplace, OR = 25.05.

CONCLUSIONS

Despite a high graft survival at 1 year, most of the patients did not regain ambulatory vision. Graft rejection, RD, and endophthalmitis were risk factors for graft failure. These factors should be considered when counseling patients regarding PKP after OGI.

Enterobacter cloacae Keratitis: Clinicomicrobiological Profiles, Risk Factors, and Outcomes

PURPOSE

The purpose of the study was to report the clinical features, risk factors, antibiotic susceptibility, and treatment outcomes in a series of Enterobacter cloacae keratitis.

METHODS

A retrospective analysis was performed of the electronic medical records of microbial keratitis caused by E. cloacae identified by the Vitek 2 system (BioMerieux, Craponne, France). We collected data pertaining to demographics, risk factors, ulcer characteristics, antibiogram, visual acuity at presentation and final follow-up, and management outcome. The main outcome measure was resolution of infection. The final visual acuity was the secondary outcome measure.

RESULTS

Ten episodes of E. cloacae keratitis in 9 patients were identified between January 2009 and December 2019. Nine (90%) cases had undergone penetrating keratoplasty and 8 were failed grafts. Other risk factors included topical steroid use and irregular ocular surface due to epithelial bullae. The mean ulcer size was 17.55 ± 13.99 mm 2 . More than 80% of isolates were sensitive to chloramphenicol, gentamicin, and colistin. Nine (90%) cases healed on medical management within 56.55 ± 26.74 days (range 9-120 d), although almost all required adjunctive procedures: tissue adhesive application (n = 6) and/or tarsorrhaphy (n = 4). One case with a near total infiltrate had a mixed infection with Kocuria kristinae requiring therapeutic penetrating keratoplasty. One case developed endophthalmitis and phthisis after the corneal infiltrate resolved.

CONCLUSIONS

E. cloacae keratitis is a rare clinical entity seen more often in immunocompromised host conditions such as failed corneal transplants with concomitant topical steroids. Most cases healed with medical management.

Case series of staged lamellar corneal grafting with thin manual Descemet's stripping endothelial keratoplasty, followed by manual deep anterior lamellar keratoplasty, as an alternative to penetrating keratoplasty

The purpose of this report is to present the outcomes of Descemet's stripping endothelial keratoplasty (DSEK), followed by deep anterior lamellar keratoplasty (DALK), as an alternative to penetrating keratoplasty (PKP) for different indications. Patients in this retrospective case series underwent manual DSEK, followed by manual DALK, for tectonic and/or visual reasons. It includes three cases that underwent DSEK followed by DALK as an alternative to PKP for the following conditions: failed PKP and stromal scarring, aphakic bullous keratopathy and herpetic stromal scarring, and herpetic corneal perforation. All cases had successful anatomical repair with visual improvement. Many corneal conditions involving endothelium and stroma have been traditionally managed with PKP. However, in certain settings with high risk of complications, this might not be an appropriate option. Therefore, for these cases, we propose management with DSEK followed by DALK as an alternative approach in a 'closed anterior chamber' fashion, which can reduce the risk of significant, sometimes irreversible, complications.

Acute corneal allograft rejection following SARS-CoV-2 vaccination-A systematic review

All documented cases of acute corneal allograft rejection following SARS-CoV-2 vaccination were examined, to characterize possible risk factors and graft outcomes. Comprehensive search (4 electronic databases: PubMed, CENTRAL, ClinicalTrials.gov, Google Scholar, plus manual search in articles' reference lists) until March 1st 2022 to identify studies reporting acute corneal allograft rejection following SARS-CoV-2 vaccination; study protocol was developed in line with PRISMA statement. We analysed demographics, allograft type, rejection prophylaxis regime at the time of vaccination, transplantation-to-vaccination time (G-Vt), vaccination-to-immune reaction onset time (V-Rt), management, best-corrected visual acuity before and after rejection, and graft survival. Of 169 titles/abstracts screened, 16 studies (n  = 36 eyes) met the inclusion criteria. Fourteen eyes (38.9%) had received >1 graft, and 11.1% of cases had history of immune reactions; 52.9% of cases occurred after the first dose. Median (P25-P75) G-Vt was 48 (10-78) months; median V-Rt was 9 (7-14) days. In eyes with resolved rejection, median time-to-resolution was 3 (1-4) weeks. Four eyes (11.1%) had partial resolution of corneal decompensation, and 5 grafts (13.9%) failed. Acute corneal allograft rejection after SARS-CoV-2 vaccination is a rare event, but may occur any time post-keratoplasty. Early recognition and prompt, aggressive treatment is warranted to optimize vision and graft survival. Well-known risk factors for rejection may be confounding factors, including the high proportion of cases with a history of previous grafts and the rejection prophylaxis regimes at the time of vaccination. Increasing immunosuppressants in the peri-vaccination period may decrease the risk of immune reactions, especially in high-risk cases.

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.

Reticular epithelial edema after penetrating keratoplasty in a patient taking netarsudil

Netarsudil is a relatively new medication for the treatment of primary open-angle glaucoma and ocular hypertension. It has been associated with red eyes and burning after instillation. Reticular epitheliopathy is a relatively rare complication of netarsudil that has been described in patients with preexisting corneal edema. We report the case of a healthy 76-year-old woman who developed reticular epitheliopathy after full-thickness penetrating keratoplasty that completely resolved following discontinuation of the medication. In cases where netarsudil is initiated for treatment of glaucoma or, off-label, endothelial dysfunction, reticular epithelial edema should be considered in patients complaining of a decline in vision and severe pain.

[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.

P-15 Utilising endothelial migration to perform deep anterior lamellar keratoplasty in eyes with deep posterior corneal scarring typically treated with penetrating keratoplasty

*Correspondence - Luis García-Onrubia: luis.garciaonrubia@gstt.nhs.uk PURPOSE: To describe a novel technique for deep anterior lamellar keratoplasty (DALK) in patients central corneal perforation and deep scarring making conventional DALK (Melles or Big Bubble) unviable. A posterior Descemet's membrane (DM) skirt has provided an adequate scaffold for the migration of the host endothelial cells.

METHODS AND ANALYSIS

A case report. A 32-year-old male with previous hydrops developed severe corneal scarring with a break in DM visible on OCT scanning. A modified DALK procedure was perform consisting of a 400µm, 8.5mm Anterior lamellar cap with a 4.5mm posterior lamellar disc, denuded of endothelial cells and containing a DM skirt.Initially, manual dissection of the and anterior 400µm of corneal stroma was performed using a modified Melles technique. The residual posterior lamellar was assessed and found to have significant residual scarring. A central 4mm optical window was performed through the posterior lamellar over the visual axis.The donor tissue was cut using a 350µm microkeratome head. The anterior cap was trephined to 8.5mm and set aside. The posterior lamellar was placed in a punch block, and the endothelial was removed using a silicone tipped cannula. The removal of endothelial cells was confirmed using trypan blue dye. A posterior lamellar graft with a 4.0mm stromal bed and a 4.5mm DM skirt was fashion using a peeling and double punch technique. The posterior lamellar graft was inserted into the optical window such that the DM skirt provided a bridge to the donor corneal endothelium. The anterior cap was sutured with a double continuous suture of 10-0 monofilament nylon. An inferior peripheral iridotomy was created, and an air bubble filling the anterior chamber was left at the end of the case.

RESULTS

The preoperative visual acuity (VA) was hand movements. Full attachment of the posterior lamellar was seen at all time-points from week one onwards. Central corneal pachymetry continued to reduce for 12 weeks. One year after the operation, with sutures in, the best spectacle-corrected VA was 6/12. The corneal graft was clear, and no rejection episodes occurred. Endothelial cell repopulation of the donor DM could be observed with specular microscopy.

CONCLUSION

The presence of DM promotes endothelial migration and healing. Modifications to traditional DALK surgery, in which DM is used to promote endothelial healing, are a viable alternative to penetrating keratoplasty. This method eliminates the risk of allograft endothelial rejection and allows a 'regenerative' for DALK to be used, offering a new modality of treatment in patients with healthy reserves of endothelial cells and deep posterior lamellar scarring.

P-12 A case of Descemet's membrane detachment following penetrating keratoplasty for keratoconus

*Correspondence - Nadeem Ahmad: nadeem.ahmad123@doctors.org.uk OBJECTIVE: To present an uncommon case of Descemet's (DM) detachment 20 years following PK for keratoconus. The detachment spontaneously resolved with conservative management.To review the literature and published case reports for the clinical course, prognosis, and managements employed for DM detachment following PK.

METHODS AND ANALYSIS

Case presentation of a patient presenting to our department and review of the literature.

RESULTS

Our patient presented with a spontaneous DM detachment 20 years after an uncomplicated PK for keratoconus. Imaging showed recurrence of corneal ectasia inferiorly, which would give this patient a poorer prognosis and higher risk of re-detachment after surgical intervention for the detachment. We opted for conservative management, after which the DM detachment spontaneously resolved and corneal thickness improved.DM detachment is an uncommon late complication of PK and pathophysiology is thought to be mechanical due to a retrocorneal membrane, or due to recurrence of corneal ectasia. The majority of published cases underwent surgery with air, SF6, or C3F8 with postoperative supine positioning, or progression to repeat PK or DSAEK if this initial treatment fails. Topical steroids can be given for conservative management.

CONCLUSION

Conservative management of DM detachment can be an option for patients with guarded prognosis, or in small detachments with no tears. Our case provides another data point on the presentation and progression of this complication to the small number of case reports in the literature.

Microbial Keratitis Associated With Penetrating Keratoplasty and Scleral Lens Wear: A Case Series

OBJECTIVES

To report on microbial keratitis (MK) in three scleral lens (SL) wearers who had undergone penetrating keratoplasty (PKP).

METHODS

This retrospective case series describes 3 cases of MK in patients who wore SLs after PKP.

RESULTS

All three patients wore SLs for visual rehabilitation for corneal irregularity induced by PKP; all three also had concurrent ocular surface disease (keratoconjunctivitis sicca and corneal exposure). Cultures identified the causative organism in two patients, and septated hyphae suggestive of fungal infection were identified in tissue removed during therapeutic PKP in the third patient. All three patients were receiving either topical or systemic immunosuppressive therapy before the infection developed.

CONCLUSIONS

Scleral lenses are often used to manage complex ocular disease, which can make it difficult to determine the precise cause of complications that arise after wearing the lenses. Multiple factors, including SL wear, may have contributed to the initial development of MK in the three patients in this case series. Patients who wear SLs after PKP should be monitored closely.

Five Cases of Corneal Graft Rejection After Recent COVID-19 Vaccinations and a Review of the Literature

PURPOSE

The purpose of this study was to report 5 cases of acute corneal graft rejection after COVID-19 vaccination and perform a review of the literature.

METHODS

This was a case series and review of literature dated on the October 10, 2021.

RESULTS

We describe 5 cases-2 patients with Descemet stripping automated endothelial keratoplasty (for Fuchs endothelial dystrophy) who presented with acute corneal graft rejection after their first dose of mRNA (BNT162) vaccine. The other 3 patients who had penetrating keratoplasty performed more than 10 years ago for keratoconus presented with acute graft rejection-2 patients after their second dose of adenovirus vector (AZD1222) vaccine and 1 patient after first dose of mRNA (BNT162) vaccine. Three patients were not using any topical steroid treatment at the time of diagnosis of graft rejection. The mean duration between vaccination and onset of symptoms was 16.86 ± 6.96 days for the mRNA vaccine and 17 ± 11.89 days for the adenovirus vector vaccine.

CONCLUSIONS

Corneal graft rejection has recently been reported after COVID-19 vaccination. Patients with keratoplasty need to be advised regarding the risk of corneal graft rejection and warning symptoms of rejection after COVID-19 vaccination. Seeking early referral to the emergency department and increasing topical steroids pre-COVID-19 and post-COVID-19 vaccination may reduce the risk of rejection.

[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.

Analysis of risk factors of rapid attenuation of graft endothelium in the early stage after penetrating keratoplasty

This study aimed to analyze the factors of rapid attenuation of graft endothelium in the early stage after penetrating keratoplasty (PKP), with a view to guiding patients with PKP to better long-term outcomes. This study included 226 patients who underwent PKP with follow-up time >1 year at the Qingdao Eye Hospital of Shandong First Medical University from January 2018 to June 2020. Medical records were retrospectively studied, and donor factors, patient factors, and surgical factors were comparatively analyzed to clarify those affecting the rapid decay of graft endothelium after PKP. The median time between excision and death >60 min and patient age >60 years were risk factors for endothelial cell loss (ECL) rate >30% at 1 month postoperatively. However, a higher percentage of patients with donor age ≤60 years and Optisol preservation solution had endothelial cell density (ECD) >2000 cells/mm² in the graft at postoperative 1 year. A year after the surgery, patients with corneal endothelial decompensation and immune rejection were at risk for ECD < 1000 cells/mm². The combined operations had a significant effect on the ECL in the early postoperative period. Patients who underwent combined extracapsular cataract extraction or intraocular lens implantation had a significantly higher rate of ECL at postoperative 1 month than other patients, and no significant effect at postoperative 1 year. However, patients without combined operations have a higher probability of maintaining a high level of graft ECD. The graft diameter also affected postoperative ECL. In patients with a larger graft diameter, attenuation of ECD was slower. The ultimate goal of PKP is to maintain graft transparency for extended periods. The use of younger donors, minimizing unnecessary operation in the anterior chamber, and minimizing immune rejection may maintain a greater donor corneal endothelium in the long term.

[Optical properties of the cornea after different modifications of penetrating keratoplasty]

PURPOSE

Comparative analysis of optical properties of the cornea after different modifications of penetrating keratoplasty.

MATERIAL AND METHODS

The study included 56 patients (56 eyes) divided into three study groups according to the surgery technique. Group I included 17 patients (17 eyes) after one-piece mushroom keratoplasty, group II - 21 patients (21 eyes) after two-piece mushroom keratoplasty and group III - 18 patients (18 eyes) after penetrating keratoplasty. In addition to standard examination methods, before surgery and in the course of the follow-up all patients underwent software-powered corneal densitometry on the anterior segment analyzer (Pentacam HR, "Oculus", Germany), as well as an assessment of the degree and regularity of postoperative astigmatism.

RESULTS

Comparison of the obtained results revealed with a high degree of confidence higher values of the total specific light scattering after two-piece mushroom keratoplasty throughout the entire observation period (p<0.05). At the same time, there was no statistically significant difference in visual acuity between the three study groups (p>0.05). A statistically significant increase in the level of induced astigmatism was revealed after penetrating keratoplasty.

CONCLUSION

The observed increase in light scattering after two-piece mushroom keratoplasty does not lead to a decrease in visual acuity. The interface in the optical zone of the cornea formed by a microkeratome does not affect the degree and regularity of induced astigmatism.

[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.

Elevated Cytokine Levels in Aqueous Humor Are Associated with Peripheral Anterior Synechiae after Penetrating Keratoplasty

Peripheral anterior synechiae (PAS) after corneal transplantation leads to refractory glaucoma and permanent loss of vision. However, the exact mechanism remains elusive. This study aimed to evaluate the association between cytokine levels in the aqueous humor (AqH) and the progression of PAS after penetrating keratoplasty (PKP). We measured 20 cytokine levels in AqH and assessed the correlation with PAS progression after PKP in 85 consecutive patients who underwent PKP. We also evaluated age-dependent alterations in PAS and cytokine levels in DBA2J mice. PAS developed in 38 (44.7%) of 85 eyes after PKP. The incidence of intraocular pressure increase after PKP was significantly greater in eyes with PAS (26.3%) than in those without PAS (2%, p = 0.0009). The PAS area at 12 months after PKP was significantly positively correlated with the preoperative levels of interleukin (IL)-6, interferon (IFN)-γ and monocyte chemotactic protein (MCP)-1 (p ≤ 0.049). In the DBA2J mice, an experimental glaucoma model that developed PAS at 50 weeks, the AqH levels of IL-2, IL-6, IL-10, IFN-γ, tumor necrosis factor-α, MCP-1 and granulocyte-macrophage colony-stimulating factor (GM-CSF) significantly increased at 50 weeks compared to 8 weeks (p ≤ 0.021). In conclusion, inflammatory alterations in the AqH microenvironment, such as high preoperative specific cytokine levels, can lead to PAS formation and glaucoma.

Acute endophthalmitis after penetrating and endothelial keratoplasty at a tertiary eye care center over a 13-year period

PURPOSE

To evaluate the clinico-microbiological profile, donor cornea risk factors, and outcomes of postkeratoplasty endophthalmitis at a tertiary care center.

METHODS

Retrospective analysis of charts of 28 consecutive patients (28 eyes) of acute endophthalmitis following either an endothelial keratoplasty (EK) or an optical penetrating keratoplasty (PK) surgery, performed between 2006 and 2018 (13-year period). Positive microbiology, identification and classification of predisposing factors, surveillance of utilized paired donors, treatment outcomes, and differences in the rate and severity of the event between optical penetrating and endothelial keratoplasty.

RESULTS

The estimated incidence of endophthalmitis was 0.23% in the entire cohort; it was 0.34% and 0.15%, after EK and PK, respectively (P = 0.049). The median time of endophthalmitis was 4.5 days postsurgery. Donor-related endophthalmitis was recognized in 7/28 (25%) eyes. Culture positivity was 68% (n = 19 of 28). Bacteria was isolated in 84% (n = 16 of 19) instances; Gram-negative bacilli were more common (87.5%; 14 of 16), and Pseudomonas species (50%; 7 of 14) was the most common Gram-negative bacterium. Majority (>75%) of the Gram-negative bacteria were resistant to all fluoroquinolones, aminoglycosides, 3rd generation cephalosporins, and meropenam; 1/3rd were resistant to imipenem; and 90% were sensitive to colistin. Treatment included intraocular antibiotic injections (96.4%), vitrectomy (42.9%), and therapeutic keratoplasty (50%). In 85.7% (24 of 28), globe was salvaged. The final vision was 20/200 or better in 39.1% (9 of 23) eyes.

CONCLUSION

EK carried a higher risk of endophthalmitis than PK in this cohort. Bacterial infection was more common in this series, with Gram negative bacilli being the commonest organisms. Multidrug resistance was common (~75%) in Gram negative isolates.

Fulminant Sphingomonas paucimobilis keratitis: case study and review of literature

Sphingomonas paucimobilis is a low-virulence gram-negative bacillus known to cause various ocular infections such as endophthalmitis, panophthalmitis and keratitis that are usually associated with an underlying risk factor such as peri-partum or postpartum phase, cataract surgery, contact lens use, neurotrophic keratopathy or ocular trauma. We report a case of spontaneously occurring perforated corneal ulcer caused by the organism in a young man managed by penetrating keratoplasty. The course was followed by endophthalmitis with graft infection culminating in phthisis bulbi despite aggressive medical and surgical management. Along with reporting this case, we also present a review of literature on ocular infections caused by the same organism.

Factors Predictive of Double Anterior Chamber Formation Following Deep Anterior Lamellar Keratoplasty

PURPOSE

To identify risk factors predictive of postoperative double anterior chamber formation after deep anterior lamellar keratoplasty (DALK).

DESIGN

Retrospective institutional cohort study.

METHODS

The study group included all consecutive eyes undergoing primary DALK between May 2015 and October 2018 at Villa Igea private hospital (Forli, Italy). The indications for surgery were categorized as (1) keratoconus without scarring; (2) keratoconus with scarring; (3) non-keratoconus without scarring; and (4) non-keratoconus with scarring. Multivariate binary logistic regression analysis was performed, introducing, as independent variables, those that reached a significance level of less than .05 in univariate analysis. The main outcome measure was whether or not postoperative double anterior chamber (AC) occurred.

RESULTS

A total of 591 eyes of 591 patients were included. The main indication for DALK was keratoconus (67.2%, n = 397), and pneumatic dissection was achieved in 72.9% (n = 431) of patients. Postoperative double AC was observed in 8.1% (n = 48) of cases. Age, intraoperative central DM perforation, type 2 bubble formation, and presence of scar in keratoconic and nonkeratoconic corneas were all associated with an increased risk of postoperative double AC formation in the univariate analysis. Manual dissection was not associated with double AC formation. The factors that remained significant in multivariate analysis were keratoconus with scarring (odds ratio [OR] = 3.56, P = .02), non-keratoconus with scarring (OR = 5.09, P = .002), intraoperative central perforation (OR = 6.09, P = .03), and type 2 bubble formation (OR = 14.17, P < .001).

CONCLUSIONS

Scarred corneas of both normal and abnormal shape are independent risk factors for double AC formation following DALK, along with intraoperative perforation and the occurrence of a type 2 bubble.

Three-Dimensional Optical Coherence Tomography Imaging For Glaucoma Associated With Boston Keratoprosthesis Type I and II

PRECIS

Three-dimensional (3D) spectral domain optical coherence tomography (OCT) volume scans of the optic nerve head (ONH) and the peripapillary area are useful in the management of glaucoma in patients with a type I or II Boston Keratoprosthesis (KPro).

PURPOSE

The purpose of this study was to report the use of spectral domain OCT in the management of glaucoma in patients with a type I or II Boston KPro.

MATERIALS AND METHODS

This study is an observational case series. Four consecutive patients with KPro implants were referred for glaucoma evaluation. A comprehensive eye examination was performed which included disc photography, visual field testing, and high-density spectral domain OCT volume scans of the ONH and the peripapillary area. 2D and 3D parameters were calculated using custom-designed segmentation algorithms developed for glaucoma management.

RESULTS

Spectral domain OCT parameters provided useful information in the diagnosis and management of 4 KPro patients. OCT parameters which can be used in KPro patients included 2D retinal nerve fiber layer (RNFL) thickness, 3D peripapillary RNFL volume, 3D peripapillary retinal thickness and volume, 3D cup volume, and 3D neuroretinal rim thickness and volume. In 3 of 4 cases where the traditional 2D RNFL thickness scan was limited by artifacts, 3D spectral domain OCT volume scans provided useful quantitative objective measurements of the ONH and peripapillary region. Therefore, 3D parameters derived from high-density volume scans as well as radial scans of the ONH can be used to overcome the limitations and artifacts associated with 2D RNFL thickness scans.

CONCLUSIONS

Spectral domain OCT volume scans offer the possibility to enhance the evaluation of KPro patients with glaucoma by using both 2D and 3D diagnostic parameters that are easily obtained in a clinic setting.

Deep Intrastromal Arcuate Keratotomy With In Situ Keratomileusis (DIAKIK) for the Treatment of High Astigmatism After Keratoplasty: 2-Year Follow-up

PURPOSE

To describe 2-year results of deep intrastromal arcuate keratotomy with in situ keratomileusis (DIAKIK) for the treatment of high astigmatism after keratoplasty.

METHODS

This prospective study included 20 eyes from 20 patients presenting with high astigmatism after keratoplasty. All were treated by two-step femtosecond laser surgery, with two intrastromal arcuate keratotomies and a corneal flap, followed a few months later by excimer photoablation after reopening of the flap.

RESULTS

At 24 months, both uncorrected (UDVA) and corrected (CDVA) distance visual acuity had improved from 1.12 ± 0.42 logMAR (20/200 Snellen) before surgery to 0.58 ± 0.23 logMAR (20/80 Snellen) (P < .001) and from 0.31 ± 0.26 logMAR (20/40 Snellen) to 0.20 ± 0.20 logMAR (20/32 Snellen) (P = .04), respectively. The mean spherical equivalent improved from -5.01 ± 4.35 to -1.54 ± 2.42 diopters. The mean efficacy index was 0.63. The mean correction index was 0.93 ± 0.32. The mean flattening index was 1.09 ± 0.75 and the mean safety index was 1.39. No graft rejection or epithelial ingrowth was observed.

CONCLUSIONS

This two-step procedure was an effective treatment for high astigmatism after keratoplasty. The use of both femtosecond and excimer lasers helped to avoid some complications that would have jeopardized the grafts. Refractive and topographic stability was good 2 years after surgery. [J Refract Surg. 2019;35(4):239-246.].

Herpes simplex virus linear endotheliitis in a post-keratoplasty patient: A case report

RATIONALE

To report a case of herpes simplex virus (HSV) linear endotheliitis in a 57-year-old male who had underwent keratoplasty 10 years ago. The characteristic linear keratic precipitates (KPs) resembled the Khodadoust line in graft rejection. The differential diagnosis is essential, because the treatment regimen is different between HSV linear endotheliitis and graft rejection.

PATIENT CONCERNS

The patient developed a sudden onset of ocular pain and a decrease in visual acuity in his right eye. The patient had received penetrating keratoplasty in the eye 10 years ago.

DIAGNOSES

The ocular disease was evaluated using several ocular examinations, including best-corrected visual acuity (BCVA), intraocular pressure, slit lamp examination, fundus examination, and aqueous humor tap. Characteristic linear endothelial KPs were found both in the host cornea and graft cornea. Stromal edema was evident in both the donor and recipient corneas. The aqueous humor was sampled for viral polymerase chain reaction (PCR) analysis. The sample was investigated for the possible presence of HSV I, HSV II, cytomegalovirus, and varicella zoster virus. The PCR was positive for HSV I and negative for HSV II, cytomegalovirus, and varicella zoster virus.

INTERVENTIONS

The patient was treated with both antiviral and steroid treatments for 1 month. Thereafter, prophylactic antiviral treatment was continued.

OUTCOMES

The subjective symptoms had improved and the cornea edema and the linear endothelial KPs had disappeared. The BCVA improved from 20/200 to 20/80.

LESSONS

HSV linear endotheliitis is the most severe form of HSV endotheliitis. This case showed characteristic endothelial KPs, which were different from the Khodadoust line of graft rejection.

Outcome of deep anterior lamellar keratoplasty patients with intraoperative Descemet's membrane perforation: A retrospective cross-sectional study

PURPOSE

To evaluate functional and anatomical outcome in patients undergoing deep anterior lamellar keratoplasty (DALK) with intraoperative Descemet's membrane (DM) perforation (macro and micro).

METHODS

A retrospective cross sectional study (January 2009 to December 2015) of sixteen eyes of sixteen patients which included nine patients of advanced keratoconus (KC), two patients with paracentral DM scarring post hydrops, KC with Bowman's membrane scarring, macular corneal dystrophy and one patient of advanced Pellucid Marginal Degeneration (PMD). All underwent DALK with intraoperative DM perforation. Big bubble technique was attempted in all except in the two patients with post hydrops DM scar. Preoperative and postoperative best corrected visual acuity (BCVA), astigmatism and endothelial count (EC) were compared.

RESULTS

Postoperative BCVA and astigmatism were found to be better and statistically significant ('p value' 0.00 and 0.003 respectively). BCVA preoperative and postoperative was 1.07± 0.3 and 0.28 ± 0.09 in LogMAR respectively and astigmatism pre and postoperative 4.14 ± 1.5 D and 2.7 ± 0.97 D respectively. Percentage decrease in EC at sixth postoperative week was 7.48% and at sixth month and 1 year postoperative was 15.1%. Two patients developed postoperative double anterior chamber and two patients developed pupillary block glaucoma and all were successfully managed.

CONCLUSION

Not all patients of intraoperative DM perforation (including macro perforation) needs to be converted to penetrating keratoplasty. DALK can be successfully done if the perforation is identified early and managed adequately. This is the only known study which has shown a large series of successful DALK even with macro perforations.