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Gururani H, Chittajallu SNSH, Doulatramani M, Chinthapenta V, Basu S, M. R. Collagen imaging reveals synergistic effects of sutures and host-donor misalignment on topographical irregularities in penetrating keratoplasty. PLoS One 2024; 19:e0308204. [PMID: 39116076 PMCID: PMC11309498 DOI: 10.1371/journal.pone.0308204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 07/18/2024] [Indexed: 08/10/2024] Open
Abstract
PURPOSE Mitigating unwanted refractive errors is crucial for surgeons to ensure quality vision after penetrating keratoplasty (PK). The primary objective of the present study is to highlight the importance of microstructural matching of the host and the donor cornea during PK on the distribution of the corneal tissue while suturing. METHODS For this purpose, the present study undertakes an in-vitro PK model to analyse the effect of suturing and host-donor misalignment on corneal birefringence. Five groups of experiments were performed using five corneoscleral buttons. In each group, N = 16 data points (corresponding to 16 simple interrupted sutures) were assessed before and after PK with five degrees of misalignments, 0°, 30°, 45°, 60° and 90° to detect the variations in corneal birefringence post-PK. The technique of digital photoelasticity is utilized to capture the corneal birefringence experimentally. RESULTS The local and global features of corneal birefringence provided interesting insights into the nuances of corneal birefringence in PK. Statistical analysis was performed to study the effects of suturing on the birefringence around the suture bites. It was observed that the interaction of the suture tension and structural misalignment between the host and the donor cornea influences the corneal birefringence in PK. Conclusions The zero-degree structural misalignment of the host and the donor tissue is preferable to minimize the topographical irregularities and related astigmatism post-PK. The findings of the present study envisage an additional step of structurally aligning the donor tissue with the host before suturing to minimize topographical irregularities in PK.
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Affiliation(s)
- Himanshu Gururani
- Department of Mechanical and Aerospace Engineering, Micro-Mechanics Lab, Indian Institute of Technology Hyderabad, Sangareddy, Telangana, India
| | - Sai Naga Sri Harsha Chittajallu
- Department of Mechanical and Aerospace Engineering, Micro-Mechanics Lab, Indian Institute of Technology Hyderabad, Sangareddy, Telangana, India
| | - Minal Doulatramani
- The Cornea Institute, LV Prasad Eye Institute, Hyderabad, Telangana, India
| | - Viswanath Chinthapenta
- Department of Mechanical and Aerospace Engineering, Micro-Mechanics Lab, Indian Institute of Technology Hyderabad, Sangareddy, Telangana, India
| | - Sayan Basu
- Professor Brien Holden Eye Research Centre, L V Prasad Eye Institute, Hyderabad, Telangana, India
- The Cornea Institute, LV Prasad Eye Institute, Hyderabad, Telangana, India
| | - Ramji M.
- Department of Mechanical and Aerospace Engineering, Engineering Optics Lab, Indian Institute of Technology Hyderabad, Sangareddy, Telangana, India
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Berger T, Seitz B, Flockerzi E, Suffo S, Flockerzi FA, Berger M, Szentmáry N, Daas L. Surgical management of complicated Descemet's membrane detachment in corneas without prior endothelial keratoplasty. Graefes Arch Clin Exp Ophthalmol 2024; 262:879-889. [PMID: 37682334 PMCID: PMC10907463 DOI: 10.1007/s00417-023-06231-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 08/24/2023] [Accepted: 08/27/2023] [Indexed: 09/09/2023] Open
Abstract
PURPOSE To provide insights into morphologic and functional features of eyes with complicated Descemet's membrane detachment (DMD) and report clinical outcomes after surgical intervention. METHODS Retrospective study of 18 eyes with complicated DMD between 2010 and 2022. Complicated DMD was defined if any of the following criteria applied: prior penetrating keratoplasty (PKP), corneal thinning, total DMD or persistent DMD after Air/Gas-Descemetopexy. Causes, surgical management, and clinical outcomes were analyzed. Scheimpflug tomography, anterior segment optical coherence tomography (AS-OCT) and histologic examination were performed to characterize corneas with DMD. RESULTS Fourteen eyes with prior PKP developed spontaneous DMD after 24.2 ± 12.9 years (range = 18 months - 47 years, median = 25.7 years). Complicated DMD without prior PKP was associated in three eyes after cataract surgery and in one eye after infectious keratitis. In cases with previous PKP, AS-OCT demonstrated rupture of Descemet's membrane (DM) in five eyes and spontaneous reattachment was found in four eyes within 8 weeks of initial diagnosis, with no rupture of DM in any of the cases. There was no rupture of DM in corneas without previous PKP. After prior keratoplasty, definitive surgical treatment was repeat PKP in 13 eyes and Air/Gas-Descemetopexy in one eye. In corneas without prior keratoplasty, three eyes underwent PKP and one eye Air/Gas-Descemetopexy. Histological examination of two corneal explants revealed a severely thinned graft-host junction and a disrupted DM close to the graft-host junction. Visual acuity improved from 1.80 ± 0.58 logMAR to 0.75 ± 0.69 logMAR after prior PKP and from 1.45 ± 0.65 logMAR to 0.85 ± 1.13 logMAR without prior PKP. The postoperative course was uneventful in 16 of 18 eyes. CONCLUSION PKP is an effective treatment option for complicated DMD, especially in ectatic corneas, whereas Air/Gas-Descemetopexy or Descemet Membrane Endothelial Keratoplasty do not address the primary issue of the curvature anomaly.
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Affiliation(s)
- Tim Berger
- Department of Ophthalmology, Saarland University Medical Center, Homburg/Saar, Germany.
| | - Berthold Seitz
- Department of Ophthalmology, Saarland University Medical Center, Homburg/Saar, Germany
| | - Elias Flockerzi
- Department of Ophthalmology, Saarland University Medical Center, Homburg/Saar, Germany
| | - Shady Suffo
- Department of Ophthalmology, Saarland University Medical Center, Homburg/Saar, Germany
| | - Fidelis A Flockerzi
- Institute of Pathology, Saarland University Medical Center, Homburg/Saar, Germany
| | - Maximilian Berger
- Department of Ophthalmology, Saarland University Medical Center, Homburg/Saar, Germany
- Dr. Rolf M. Schwiete Center for Limbal Stem Cell and Congenital Aniridia Research, Saarland University, Homburg/Saar, Germany
| | - Nóra Szentmáry
- Dr. Rolf M. Schwiete Center for Limbal Stem Cell and Congenital Aniridia Research, Saarland University, Homburg/Saar, Germany
| | - Loay Daas
- Department of Ophthalmology, Saarland University Medical Center, Homburg/Saar, Germany
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Lucisano A, Scorcia V, Taloni A, Rossi C, Gioia R, Giannaccare G. Impact of topographic localization of corneal ectasia on the outcomes of deep anterior lamellar keratoplasty employing large (9 mm) versus conventional diameter (8 mm) grafts. Eye (Lond) 2023; 37:3477-3483. [PMID: 37081075 PMCID: PMC10630389 DOI: 10.1038/s41433-023-02536-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 03/30/2023] [Accepted: 04/06/2023] [Indexed: 04/22/2023] Open
Abstract
OBJECTIVES Visual and topographic outcomes of large (9.0 mm) versus conventional (8.0 mm) deep anterior lamellar keratoplasty (DALK) for the treatment of keratoconus (KC) were compared in relation to the different localization of the corneal ectasia (within or beyond the central 8.0 mm). METHODS This is a retrospective, comparative case series. Preoperatively, the topographic extension of the conus was calculated by measuring the distance from the geometric center of the cornea and the outermost point of the corneal ectasia (ectasia <8.0 mm, group A; ectasia ≥8.0 mm, group B). DALK was performed using both small grafts (8.0 mm, group 1) and large grafts (9.0 mm, group 2). Best-corrected visual acuity and topographic astigmatism were evaluated preoperatively (T0) and postoperatively after complete suture removal (1 year, T1). RESULTS Data from 224 eyes of 196 patients (mean age 37.6 ± 15.1 years) were evaluated. Topographic astigmatism improved from T0 to T1 (4.94 ± 2.92 diopters (D) [95% CI, 4.56-5.33] vs 4.19 ± 2.45 D [95% CI, 3.87-4.51], p = 0.001). There was no significant difference in postoperative topographic cylinder between group 1 and group 2 when considering eyes with corneal ectasia <8.0 mm (group 1 A, 4.15 ± 2.19 D [95% CI, 3.64-4.66] vs group 2 A, 3.65 ± 2.13 D [95% CI, 2.92-4.38], p = 0.14); conversely, the difference was significant considering eyes with corneal ectasia ≥8.0 mm (group 1B, 4.74 ± 2.90 D [95% CI, 4.09-5.38] vs group 2B, 3.68 ± 1.94 D [95% CI, 3.10-4.26], p = 0.02). CONCLUSIONS Large 9.0-mm DALK provided better anatomical outcomes compared to conventional 8.0-mm DALK, particularly in eyes with corneal ectasia extending beyond the central 8.0 mm.
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Affiliation(s)
- Andrea Lucisano
- Department of Ophthalmology, University Magna Graecia of Catanzaro, Viale Europa, Catanzaro, Italy
| | - Vincenzo Scorcia
- Department of Ophthalmology, University Magna Graecia of Catanzaro, Viale Europa, Catanzaro, Italy.
| | - Andrea Taloni
- Department of Ophthalmology, University Magna Graecia of Catanzaro, Viale Europa, Catanzaro, Italy
| | - Costanza Rossi
- Department of Ophthalmology, University Magna Graecia of Catanzaro, Viale Europa, Catanzaro, Italy
| | - Raffaella Gioia
- Department of Ophthalmology, University Magna Graecia of Catanzaro, Viale Europa, Catanzaro, Italy
| | - Giuseppe Giannaccare
- Department of Ophthalmology, University Magna Graecia of Catanzaro, Viale Europa, Catanzaro, Italy
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Fathai H, Geerling G, Menzel-Severing J. Indications and outcomes of keratoplasty ≤ 5.5 mm diameter ("mini-keratoplasty"). BMC Ophthalmol 2023; 23:408. [PMID: 37817122 PMCID: PMC10563242 DOI: 10.1186/s12886-023-03150-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 09/21/2023] [Indexed: 10/12/2023] Open
Abstract
PURPOSE To report indications and clinical outcomes of corneal grafts ≤ 5.5 mm in diameter ("mini-KP") in a German tertiary referral center. METHODS Patients who had undergone mini-KP to treat corneal ulcers with or without perforation between 2011 and 2018 at the Department of Ophthalmology, University of Düsseldorf, Germany, were identified from the local keratoplasty registry. All patient records were reviewed for age, gender, laterality, systemic and ophthalmological diseases, etiology of the corneal ulcerative disease, pre- and postoperative visual acuity over a follow-up time of up to 12 months, graft size, postoperative complications and the need for and timing of further corneal interventions. RESULTS 37 eyes of 37 patients (male: n = 20; female: n = 17) with a mean age (± standard deviation) at presentation of 70 ± 18.8 years (range: 22-92 years) were identified. Most common etiologies were neurotrophic keratopathy (n = 15), dysfunctional tear syndrome (n = 9) and atopic keratoconjunctivitis (9). Mean graft diameter was 4.51 ± 0.63 mm (range: 3-5.5 mm). 23/37 eyes (62%) required no further intervention in the acute phase. 14/37 patients (38%) required secondary corneal intervention, due to complications. One-year graft survival was 78.4%. One eye had to be eviscerated due to recurrent corneal ulceration and endophthalmitis. 36 of 37 eyes were preserved. We found a highly significant correlation between type 2 diabetes and the development of postoperative complications (r = .46; p = .005). Corrected distance visual acuity (CDVA) improved from 1.42 ± 0.75 logMAR to 0.9 ± 0.65 logMAR postoperatively (t (23) = 5.76; p < .001). CONCLUSION Mini-KP can be used successfully in eyes with advanced corneal ulcers due to various infectious and noninfectious etiologies to restore tectonic stability in the long-term and with moderate visual gains.
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Affiliation(s)
- Hila Fathai
- Department of Ophthalmology, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Gerd Geerling
- Department of Ophthalmology, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
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Panthagani J, Law EM, Chipeta C, Roberts H, Myerscough J. High Astigmatism After Conventional Diameter Deep Anterior Lamellar Keratoplasty in Keratoconus Can Be Successfully Managed With Repeat Wide Diameter Deep Anterior Lamellar Keratoplasty. Cornea 2023; 42:1057-1061. [PMID: 37126842 DOI: 10.1097/ico.0000000000003298] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 03/26/2023] [Indexed: 05/03/2023]
Abstract
PURPOSE The aim of this study was to describe a new surgical technique to replace a conventional diameter (≤8 mm) deep anterior lamellar keratoplasty (DALK) graft with associated high astigmatism refractory to corneal-based astigmatic procedure/intolerance to contact lenses with a larger diameter (≥9 mm) DALK graft to improve best spectacle-corrected visual acuity (BSCVA). METHODS Two eyes from 2 keratoconic patients at Southend University Hospital between December 2019 and June 2021 with a minimum follow-up of 17 months were evaluated. The primary outcome of interest was Snellen BSCVA with a secondary outcome of topographic cylinder. RESULTS Patient 1 had undergone initial 8 mm diameter DALK, with residual keratometric astigmatism of nearly 12 diopters (D) postoperatively despite numerous astigmatic interventions, with a BSCVA of 6/60, before undergoing 9 mm diameter repeat modified DALK. After suture removal and subsequent in-the-wound blunt manual relaxing incisions, the patient had a final keratometric astigmatism of 3.5 D, manifest refraction of plano/-3.50 × 175, and a BSCVA of 6/9. Patient 2 had undergone initial 7.75 mm diameter DALK, with residual keratometric astigmatism of 10.5 D with a BSCVA of counting fingers. The patient underwent 9 mm repeat modified DALK with final residual keratometric astigmatism of 3.1 D after suture removal, manifest refraction of -1.00/-2.75 × 25, and BSCVA of 6/9. CONCLUSIONS Wide diameter DALK (>9 mm) is effective in the management of conventional diameter DALK (≤8 mm) associated high astigmatism in keratoconus. Creation of a peripheral posterior stromal shoulder also allows safe further titration of residual astigmatism if needed.
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Affiliation(s)
- Jesse Panthagani
- Department of Ophthalmology, Southend NHS University Hospital, Southend-on-Sea, United Kingdom
| | - Elizabeth M Law
- Department of Ophthalmology, Southend NHS University Hospital, Southend-on-Sea, United Kingdom
| | - Chimwemwe Chipeta
- Department of Ophthalmology, Southend NHS University Hospital, Southend-on-Sea, United Kingdom
| | - Harry Roberts
- West of England Eye Unit, Royal Devon University Healthcare, NHS Foundation Trust, Exeter, United Kingdom; and
| | - James Myerscough
- Department of Ophthalmology, Southend NHS University Hospital, Southend-on-Sea, United Kingdom
- University of Plymouth, Faculty of Medicine and Dentistry, United Kingdom
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Miura M, Leon P, Nahum Y, Böhm MS, Mimouni M, Belin MW, Johns L, Ciolino JB. Recurrent Keratoconus: Corneal Transplants for Keratoconus Develop Tomographic Ectatic Changes. Cornea 2023; 42:708-713. [PMID: 36730373 DOI: 10.1097/ico.0000000000003149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 08/04/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE The purpose of this study was to evaluate postoperative Scheimpflug imaging changes during the first 5 years after penetrating keratoplasty (PK) in patients with keratoconus (KC). METHODS This retrospective, interventional case series includes 31 eyes of 31 patients who underwent their first PK with a history of KC. Postoperative Scheimpflug imaging was performed 3 months after the removal of the last suture (baseline) and then repeated 3 and 5 years after the PK. Demographic data, donor and host trephination diameter, and Scheimpflug imaging (Pentacam HR, Oculus, Germany) parameters indicative of ectasia were analyzed to evaluate postoperative graft changes that occur after PK. RESULTS The maximal keratometry (Kmax) progressed significantly between baseline (53.5 ± 6.1 D) and postoperative year 3 and year 5 [56.5 ± 6.1 diopter (D) and 58.8 ± 7.9 D, P < 0.001]. Significant changes were also observed for the anterior best fit sphere and posterior best fit sphere ( P < 0.001 for 3 and 5 years compared with baseline). Kmax increased by at least 2 Ds for 74.2% of patients and up to 7 Ds or more for 25.8% of the patients. A significant inverse correlation was observed for host trephine size and progression of Kmax (r = -0.52, P = 0.01), which indicated that larger host trephination size was associated with a smaller increase in postoperative Kmax. CONCLUSIONS Tomographic graft changes indicative of ectasia were observed within 3 to 5 years after PK in patients with KC. These changes were observed more frequently and sooner after corneal transplants than previously reported.
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Affiliation(s)
- Maria Miura
- Schepens Eye Research Institution, Massachusetts Eye and Ear Infirmary, Department of Ophthalmology, Harvard Medical School, Boston, MA
- Department of Ophthalmology, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Pia Leon
- Schepens Eye Research Institution, Massachusetts Eye and Ear Infirmary, Department of Ophthalmology, Harvard Medical School, Boston, MA
| | - Yoav Nahum
- Department of Ophthalmology, Rabin Medical Center, Petach Tikva, Israel
- Sackler faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Myriam S Böhm
- Schepens Eye Research Institution, Massachusetts Eye and Ear Infirmary, Department of Ophthalmology, Harvard Medical School, Boston, MA
- Department of Ophthalmology, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Michael Mimouni
- Sackler faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel; and
| | - Michael W Belin
- Ophthalmology & Vision Science, University of Arizona, Marana, AZ
| | - Lynette Johns
- Schepens Eye Research Institution, Massachusetts Eye and Ear Infirmary, Department of Ophthalmology, Harvard Medical School, Boston, MA
| | - Joseph B Ciolino
- Schepens Eye Research Institution, Massachusetts Eye and Ear Infirmary, Department of Ophthalmology, Harvard Medical School, Boston, MA
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Borgia A, Romano V, Romano D, Pagano L, Vagge A, Giannaccare G, Ahmed M, Gadhvi K, Menassa N, Ahmad M, Kaye S, Coco G. Managing Post-Keratoplasty Astigmatism: High-Tech vs. Low-Tech Imaging Techniques for Guiding Suture Manipulation. J Clin Med 2023; 12:jcm12103462. [PMID: 37240568 DOI: 10.3390/jcm12103462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Accepted: 05/12/2023] [Indexed: 05/28/2023] Open
Abstract
Astigmatism is a visually significant condition that can develop after keratoplasty. The management of post-keratoplasty astigmatism can be performed both when transplant sutures are in place and when they have been removed. Fundamental for astigmatism management is its identification and characterization in terms of type, amount, and direction. Commonly, post-keratoplasty astigmatism is evaluated through corneal tomography or topo-aberrometry; however, many other techniques can be used in case these instruments are not readily available. Here, we describe several low-tech and high-tech techniques used for post-keratoplasty astigmatism detection in order to quickly understand if it contributes to low vision quality and to determine its characteristics. The management of post-keratoplasty astigmatism through suture manipulation is also described.
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Affiliation(s)
- Alfredo Borgia
- Eye Unit, Humanitas-Gradenigo Hospital, 10153 Turin, Italy
- Department of Corneal Diseases, St. Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool L7 8YE, UK
| | - Vito Romano
- Department of Corneal Diseases, St. Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool L7 8YE, UK
- Eye Clinic, Department of Neurological and Vision Sciences, University of Brescia, 25125 Brescia, Italy
| | - Davide Romano
- Eye Clinic, Department of Neurological and Vision Sciences, University of Brescia, 25125 Brescia, Italy
- Eye Unit, University Hospitals of Leicester, NHS Trust, Leicester LE1 5WW, UK
| | - Luca Pagano
- Department of Corneal Diseases, St. Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool L7 8YE, UK
| | - Aldo Vagge
- IRCCS Ospedale Policlinico San Martino, University Eye Clinic of Genoa, 16132 Genova, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health 19 (DiNOGMI), University of Genoa, 16132 Genova, Italy
| | - Giuseppe Giannaccare
- Department of Ophthalmology, University Magna Græcia of Catanzaro, 88100 Catanzaro, Italy
| | - Mahmoud Ahmed
- Department of Corneal Diseases, St. Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool L7 8YE, UK
| | - Kunal Gadhvi
- Department of Corneal Diseases, St. Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool L7 8YE, UK
| | - Nardine Menassa
- Department of Corneal Diseases, St. Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool L7 8YE, UK
| | - Mohammad Ahmad
- Department of Corneal Diseases, St. Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool L7 8YE, UK
| | - Stephen Kaye
- Department of Corneal Diseases, St. Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool L7 8YE, UK
| | - Giulia Coco
- Department of Corneal Diseases, St. Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool L7 8YE, UK
- Department of Clinical Science and Translational Medicine, University of Rome Tor Vergata, 00133 Rome, Italy
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8
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Tischer N, Zemova E, Maamri A, Pfeiffer M, Reinert U, Sideroudi H, Seitz B. [Immune reaction after penetrating keratoplasty depending on graft size and centration]. DIE OPHTHALMOLOGIE 2023; 120:36-42. [PMID: 35925343 DOI: 10.1007/s00347-022-01672-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 05/20/2022] [Accepted: 05/24/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND Immune reaction (IR) after penetrating keratoplasty (PKP) is a serious complication with a high risk of graft failure. The aim of this study was to analyze and evaluate the risk factors for IR, in particular, the influence of graft size and centration. PATIENTS AND METHODS A total of 2133 patients who underwent PKP between January 2009 and July 2019 were included in this retrospective study. The following endpoints were analyzed: frequency of IR, graft origin, donor and patient age, diagnosis, corneal diameter and ratio of the graft size to the recipient cornea size. In addition, the role of graft centration, with the help of distance measurements of the graft margins to the vascularized limbus at four locations, was investigated in detail. RESULTS Overall, 8.25% of patients suffered from IR during the observational period. The frequency of IR was significantly correlated (p < 0.001) with the ratio of the graft size to the recipient cornea size. In addition, a statistically significant correlation was found between the occurrence of IR and a small distance to the limbal margins in the Y‑axis (inferior and superior). In particular, the correlation coefficient was larger at the inferior limbus (p < 0.001). CONCLUSION An IR after PKP is a not uncommon complication and is significantly related to graft size and centration. A large graft chosen in relation to the recipient cornea and the proximity of the graft to the vascularized limbus at the inferior and superior sites significantly correlate with the occurrence of IR. These are important risk factors for graft survival, which can be influenced by the corneal microsurgeon and could possibly be further optimized in the future.
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Affiliation(s)
- N Tischer
- Klinik für Augenheilkunde, Universitätsklinikum des Saarlandes (UKS), Homburg/Saar, Deutschland.
| | - E Zemova
- Klinik für Augenheilkunde, Universitätsklinikum des Saarlandes (UKS), Homburg/Saar, Deutschland
| | - A Maamri
- Klinik für Augenheilkunde, Universitätsklinikum des Saarlandes (UKS), Homburg/Saar, Deutschland
| | - M Pfeiffer
- Klinik für Augenheilkunde, Universitätsklinikum des Saarlandes (UKS), Homburg/Saar, Deutschland
| | - U Reinert
- Klinik für Augenheilkunde, Universitätsklinikum des Saarlandes (UKS), Homburg/Saar, Deutschland
| | - H Sideroudi
- Klinik für Augenheilkunde, Universitätsklinikum des Saarlandes (UKS), Homburg/Saar, Deutschland
| | - B Seitz
- Klinik für Augenheilkunde, Universitätsklinikum des Saarlandes (UKS), Homburg/Saar, Deutschland
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Regular and irregular astigmatism of bullous keratopathy using Fourier harmonic analysis with anterior segment optical coherence tomography. Sci Rep 2022; 12:17865. [PMID: 36284222 PMCID: PMC9596404 DOI: 10.1038/s41598-022-22144-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 10/10/2022] [Indexed: 01/20/2023] Open
Abstract
Bullous keratopathy (BK) is known to present with corneal edema and Descemet's folds, which can cause corneal astigmatism. However, no report quantitatively evaluated BK astigmatism by separating it into regular and irregular astigmatism. This study investigated the regular and irregular astigmatism of the anterior and posterior corneal surface with Fourier harmonic analysis and anterior segment optical coherence tomography. Preoperative data from 43 eyes of 41 BK patients who received corneal endothelial transplantation were compared with the data from 43 eyes of 43 subjects without corneal disease. Anterior and posterior cylinder power, central corneal thickness (CCT) and thinnest corneal thickness were significantly greater in BK. With Fourier harmonic analysis, BK eyes were found to have significantly larger anterior and posterior regular astigmatism, asymmetry component and higher-order irregularity. Asymmetry component and higher-order irregularity that accounted for the posterior irregular astigmatism increased as CCT increased in BK. Higher-order irregularity in the posterior cornea also positively correlated with worsening best corrected visual acuity. Subgroup analysis found significant correlations between CCT and posterior higher-order irregularity for intraocular surgery and laser iridotomy, but not Fuchs endothelial corneal dystrophy. This study has significance in that it revealed the characteristics of the corneal posterior irregular astigmatism of BK.
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10
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Seitz B, Daas L, Wykrota AA, Flockerzi E, Suffo S. Graft Failure after PKP and DMEK: What is the Best Option? Klin Monbl Augenheilkd 2022; 239:775-785. [PMID: 35488100 DOI: 10.1055/a-1774-4862] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Corneal transplantation is the most commonly performed human tissue transplantation procedure worldwide. Due to the large number of grafts, corneal graft failure has become one of the most common indications for corneal transplantation for immunological and non-immunological reasons (e.g. recurrence of underlying disease, high intraocular pressure, grafted guttae, transmitted HSV or CMV infection). The relatively recently developed lamellar grafting techniques have introduced certain potential complications that may lead to graft failure and require approaches other than penetrating keratoplasty for re-grafting. On the other hand, these new lamellar techniques also offer new possibilities for salvaging failed penetrating grafts, with potential advantages over successive penetrating keratoplasties, such as lower intraoperative risks, faster visual rehabilitation and reduced risk of immune reaction. Today, the patient with good healing who is satisfied with his graft before endothelial decompensation, with low astigmatism and no stromal scars, represents the optimal condition for DMEK after PKP. This can also be combined with phacoemulsification (so-called triple DMEK). Otherwise, a penetrating re-keratoplasty with a larger graft (typically excimer laser repeat PKP 8.5/8.6 mm) is performed to treat edema, scars and irregular astigmatism simultaneously. The medical history carries weight in this decision! Re-DMEK in case of graft failure after DMEK and DSAEK does not require any modification of the standard technique and leads to good visual acuity results if performed quickly. If there is clear stromal scarring after multiple (external) DMEKs, PKP can also be considered to rectify the situation. Otherwise causeless recurrent graft failures must suggest herpetic or CMV endotheliitis and, after PCR analysis of the aqueous humour aspirate, be treated appropriately with medication.
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Affiliation(s)
- Berthold Seitz
- Klinik für Augenheilkunde, Universitätsklinikum des Saarlandes (UKS), Homburg (Saar), Deutschland
| | - Loay Daas
- Klinik für Augenheilkunde, Universitätsklinikum des Saarlandes (UKS), Homburg (Saar), Deutschland
| | - Agata Anna Wykrota
- Klinik für Augenheilkunde, Universitätsklinikum des Saarlandes (UKS), Homburg (Saar), Deutschland
| | - Elias Flockerzi
- Klinik für Augenheilkunde, Universitätsklinikum des Saarlandes (UKS), Homburg (Saar), Deutschland
| | - Shady Suffo
- Klinik für Augenheilkunde, Universitätsklinikum des Saarlandes (UKS), Homburg (Saar), Deutschland
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11
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Nuzzi R, Burato C, Tridico F, Nuzzi A, Caselgrandi P. Advantages of Double Running Sutures in Astigmatism After Penetrating Keratoplasty. Clin Ophthalmol 2022; 16:797-802. [PMID: 35321045 PMCID: PMC8934865 DOI: 10.2147/opth.s355538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 02/22/2022] [Indexed: 11/23/2022] Open
Abstract
Background Methods Results Conclusion
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Affiliation(s)
- Raffaele Nuzzi
- Eye Clinic Section, Department of Surgical Sciences, University of Turin, Turin, Italy
- Correspondence: Raffaele Nuzzi, Eye Clinic Section, Department of Surgical Sciences, University of Turin, Turin, Italy, Email
| | - Claudio Burato
- Eye Clinic Section, Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Federico Tridico
- Eye Clinic Section, Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Alessia Nuzzi
- Department of Clinical Sciences and Community Health, Eye Clinic San Giuseppe Hospital, IRCCS Multimedica, University of Milan, Milan, Italy
| | - Paolo Caselgrandi
- Eye Clinic Section, Department of Surgical Sciences, University of Turin, Turin, Italy
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12
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Pagano L, Shah H, Al Ibrahim O, Gadhvi KA, Coco G, Lee JW, Kaye SB, Levis HJ, Hamill KJ, Semeraro F, Romano V. Update on Suture Techniques in Corneal Transplantation: A Systematic Review. J Clin Med 2022; 11:1078. [PMID: 35207352 PMCID: PMC8877912 DOI: 10.3390/jcm11041078] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 02/15/2022] [Accepted: 02/15/2022] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Luca Pagano
- St. Paul’s Eye Unit, Royal Liverpool University Hospital, Liverpool L7 8XP, UK; (H.S.); (K.A.G.); (G.C.); (J.W.L.); (S.B.K.)
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090 Milan, Italy
| | - Haider Shah
- St. Paul’s Eye Unit, Royal Liverpool University Hospital, Liverpool L7 8XP, UK; (H.S.); (K.A.G.); (G.C.); (J.W.L.); (S.B.K.)
| | - Omar Al Ibrahim
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, Ophthalmology Clinic, University of Brescia, 25121 Brescia, Italy; (O.A.I.); (F.S.); (V.R.)
| | - Kunal A. Gadhvi
- St. Paul’s Eye Unit, Royal Liverpool University Hospital, Liverpool L7 8XP, UK; (H.S.); (K.A.G.); (G.C.); (J.W.L.); (S.B.K.)
| | - Giulia Coco
- St. Paul’s Eye Unit, Royal Liverpool University Hospital, Liverpool L7 8XP, UK; (H.S.); (K.A.G.); (G.C.); (J.W.L.); (S.B.K.)
| | - Jason W. Lee
- St. Paul’s Eye Unit, Royal Liverpool University Hospital, Liverpool L7 8XP, UK; (H.S.); (K.A.G.); (G.C.); (J.W.L.); (S.B.K.)
- School of Medicine, University of Liverpool, Liverpool L69 3BX, UK
| | - Stephen B. Kaye
- St. Paul’s Eye Unit, Royal Liverpool University Hospital, Liverpool L7 8XP, UK; (H.S.); (K.A.G.); (G.C.); (J.W.L.); (S.B.K.)
- Department of Eye and Vision Science, University of Liverpool, Liverpool L69 3BX, UK; (H.J.L.); (K.J.H.)
| | - Hannah J. Levis
- Department of Eye and Vision Science, University of Liverpool, Liverpool L69 3BX, UK; (H.J.L.); (K.J.H.)
| | - Kevin J. Hamill
- Department of Eye and Vision Science, University of Liverpool, Liverpool L69 3BX, UK; (H.J.L.); (K.J.H.)
| | - Francesco Semeraro
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, Ophthalmology Clinic, University of Brescia, 25121 Brescia, Italy; (O.A.I.); (F.S.); (V.R.)
| | - Vito Romano
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, Ophthalmology Clinic, University of Brescia, 25121 Brescia, Italy; (O.A.I.); (F.S.); (V.R.)
- Department of Eye and Vision Science, University of Liverpool, Liverpool L69 3BX, UK; (H.J.L.); (K.J.H.)
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Pellegrini M, Furiosi L, Yu AC, Giannaccare G, Scuteri G, Gardeli I, Busin M, Bovone C, Spena R. Outcomes of cataract surgery with toric intraocular lens implantation after keratoplasty. J Cataract Refract Surg 2022; 48:157-161. [PMID: 34174044 DOI: 10.1097/j.jcrs.0000000000000730] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 06/16/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE To evaluate the efficacy and predictability of cataract extraction with toric intraocular lens (IOL) implantation after deep anterior lamellar keratoplasty (DALK) or mushroom penetrating keratoplasty (PK). SETTING Villa Igea Hospital, Forlì, Italy. DESIGN Prospective case series. METHODS Toric IOL implantation was offered to patients with cataract, corneal astigmatism >1.5 diopters (D) and regular central corneal topography after complete suture removal. Phacoemulsification was performed through a 2.4 mm scleral tunnel and an enVista monofocal toric MX60T or Eyecryl monofocal toric IOL was inserted in the capsular bag. Main outcome measures were uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), manifest refraction, total prediction error, and IOL misalignment. RESULTS 37 consecutive patients who had previously undergone either DALK (n = 27, 73%) or 2-piece mushroom PK (n = 10, 27%) were included. All patients completed the 6-month follow-up. The mean toric IOL power was 5.3 ± 1.1 D. Both UDVA and CDVA significantly improved (from 1.02 ± 0.27 to 0.46 ± 0.31 logMAR and from 0.65 ± 0.27 to 0.11 ± 0.12 logMAR, respectively; P < .001). 20 eyes (54%) reached UDVA ≥20/40, whereas 35 eyes (95%) reached a CDVA ≥20/40. Final refractive astigmatism was 0.93 ± 0.87 D, with 35 eyes (95%) within 2 D. Prediction error was ≤1 D in 18 eyes (49%). Absolute IOL misalignment was 3.3 ± 3.5 degrees. CONCLUSIONS Toric IOL implantation in postkeratoplasty eyes allowed reduction of refractive astigmatism to predictably low levels with concomitant improved visual outcomes.
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Affiliation(s)
- Marco Pellegrini
- From the Department of Translational Medicine, University of Ferrara, Ferrara, Italy (Pellegrini, Furiosi, Yu, Gardeli, Busin, Bovone, Spena); Department of Ophthalmology, Ospedali Privati Forlì "Villa Igea," Forlì, Italy (Pellegrini, Furiosi, Yu, Gardeli, Busin, Bovone, Spena); Istituto Internazionale per la Ricerca e Formazione in Oftalmologia (IRFO), Forlì, Italy (Pellegrini, Furiosi, Yu, Busin, Bovone, Spena); Department of Ophthalmology, Magna Graecia University of Catanzaro, Catanzaro, Italy (Giannaccare, Scuteri); General Hospital of Athens "G. Gennimatas," Athens, Greece (Gardeli)
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14
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Budnikova EA, Trufanov SV, Novikov IA, Voronin GV. [Optical properties of the cornea after different modifications of penetrating keratoplasty]. Vestn Oftalmol 2022; 138:162-168. [PMID: 36287151 DOI: 10.17116/oftalma2022138052162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
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.
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Affiliation(s)
| | - S V Trufanov
- Research Institute of Eye Diseases, Moscow, Russia
| | - I A Novikov
- Research Institute of Eye Diseases, Moscow, Russia
| | - G V Voronin
- Research Institute of Eye Diseases, Moscow, Russia
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
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15
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Xanthopoulou K, Milioti G, Seitz B. Need for explantation of an intrastromal titan ring after penetrating keratoplasty in two patients. Eur J Ophthalmol 2022; 32:NP35-NP41. [DOI: 10.1177/1120672120962031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The most severe complications after penetrating keratoplasty (PKP) include high astigmatism and immunological graft reaction. The introduction of the corneal intrastromal titan ring by Krumeich intended to reduce the incidence of both complications. We present two patients with keratoconus who referred to our department after a PKP combined with the implantation of an intrastromal ring. The first patient suffered from bulbar pain and headaches. The second patient suffered from postoperative high myopia, irregular astigmatism and was contact lens intolerant. In the first patient we recognized anterior movement of the ring inside the stroma and decided to remove it. The second patient was found to have extreme bulging of the transplant. We removed the ring and sequentially performed a repeat-PKP. In both patients the implantation of the ring failed to decrease the postoperative astigmatism and caused symptoms that affected the patients’ everyday life. Therefore, we recommend not to use this titan ring.
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Affiliation(s)
| | - Georgia Milioti
- Department of Ophthalmology, Saarland University Medical Center, Homburg/Saar, Germany
| | - Berthold Seitz
- Department of Ophthalmology, Saarland University Medical Center, Homburg/Saar, Germany
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16
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Deshmukh R, Nair S, Vaddavalli PK, Agrawal T, Rapuano CJ, Beltz J, Vajpayee RB. Post-penetrating keratoplasty astigmatism. Surv Ophthalmol 2021; 67:1200-1228. [PMID: 34808143 DOI: 10.1016/j.survophthal.2021.11.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 11/06/2021] [Accepted: 11/15/2021] [Indexed: 10/19/2022]
Abstract
Postoperative astigmatism is one of the common complications affecting visual outcomes after a penetrating keratoplasty. It can result from various factors related to host, donor and surgical technique, resulting in suboptimal visual outcome. While some of the measures taken during preoperative planning and during actual surgery can reduce the magnitude of postoperative astigmatism, postoperative correction of astigmatism is often required in cases with high degrees of astigmatism. When spectacles and contact lenses fail to provide optimal visual outcomes, various surgical techniques that include astigmatic keratotomy, compression sutures, toric intraocular lens placement, and laser refractive procedures can be considered. When none of these techniques are able to achieve a desired result with in the acceptable optical range, a repeat keratoplasty is considered a last option. We discuss the various causes and management of complication of postoperative astigmatism occurring after a full thickness corneal transplantation surgery.
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Affiliation(s)
| | - Sridevi Nair
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | | | - Tushar Agrawal
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | | | | | - Rasik B Vajpayee
- Royal Victorian Eye and Ear Hospital, Melbourne, Australia; Vision Eye Institute, Melbourne, Australia; University of Melbourne, Australia
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17
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Modified big-bubble for deep anterior lamellar keratoplasty. J Cataract Refract Surg 2021; 47:e6-e9. [PMID: 33149044 DOI: 10.1097/j.jcrs.0000000000000469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 09/20/2020] [Indexed: 11/25/2022]
Abstract
A new technique of air injection is described for big-bubble deep anterior lamellar keratoplasty (DALK) in eyes with keratoconus, along with a comparative analysis of the original technique. Fifty eyes were analyzed in each group. The mean steep keratometry and anterior chamber depth distribution were comparable between the 2 groups. The mean size of type 1 bubble achieved with single air injection (Group 1) was 7.8 ± 0.4 mm (range 6.5 to 8.5 mm), and with sequential air injection (Group 2) was 8.5 ± 0.3 (range 8 to 9 mm) (P < .001). Intraoperative complications of spontaneous bursting of bubble in 1 eye (2%) and peripheral microperforation in 3 eyes (6%) occurred only in Group 1. The modified technique of big-bubble DALK using sequential air injection aided by paracentesis to lower intraocular pressure allowed enlargement of a type 1 bubble in a safe and controlled manner with minimal risk for complications.
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18
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Seitz B, Daas L, Hamon L, Xanthopoulou K, Goebels S, Spira-Eppig C, Razafimino S, Szentmáry N, Langenbucher A, Flockerzi E. [Stage-appropriate treatment of keratoconus]. Ophthalmologe 2021; 118:1069-1088. [PMID: 34181061 PMCID: PMC8492599 DOI: 10.1007/s00347-021-01410-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2021] [Indexed: 12/28/2022]
Abstract
Keratoconus (KC) is a progressive cone-shaped corneal protrusion that causes paracentral thinning at the apex of the cone and typically occurs asymmetrically on both sides. After a careful anamnesis and classification of the degree of severity a targeted treatment appropriate to the stage of the disease is available. If the visual acuity is no longer sufficient, rigid gas-permeable contact lenses (CL) are fitted by a specialist. Riboflavin UVA cross-linking (CXL) is recommended in cases of progression and visual acuity that is still useful for the patient. Intracorneal ring segments (ICRS) are indicated for CL intolerance in cases of reduced visual acuity and a clear central cornea. If the stage is more advanced, deep anterior lamellar keratoplasty (DALK) or penetrating keratoplasty (PKP) is recommended. A PKP is contraindicated in acute KC but deep stromal sutures for readaptation of the Descemet tear with gas filling of the anterior chamber can considerably shorten the course. Almost no other eye disease is nowadays as easily accessible for an early instrument-based diagnosis and stage-appropriate treatment as KC.
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Affiliation(s)
- B Seitz
- Klinik für Augenheilkunde und Hochschulambulanz, Universitätsklinikum des Saarlandes UKS, 66421, Homburg/Saar, Deutschland.
| | - L Daas
- Klinik für Augenheilkunde und Hochschulambulanz, Universitätsklinikum des Saarlandes UKS, 66421, Homburg/Saar, Deutschland
| | - L Hamon
- Klinik für Augenheilkunde und Hochschulambulanz, Universitätsklinikum des Saarlandes UKS, 66421, Homburg/Saar, Deutschland
| | - K Xanthopoulou
- Klinik für Augenheilkunde und Hochschulambulanz, Universitätsklinikum des Saarlandes UKS, 66421, Homburg/Saar, Deutschland
| | - S Goebels
- Klinik für Augenheilkunde und Hochschulambulanz, Universitätsklinikum des Saarlandes UKS, 66421, Homburg/Saar, Deutschland
| | - C Spira-Eppig
- Klinik für Augenheilkunde und Hochschulambulanz, Universitätsklinikum des Saarlandes UKS, 66421, Homburg/Saar, Deutschland
| | - S Razafimino
- Klinik für Augenheilkunde und Hochschulambulanz, Universitätsklinikum des Saarlandes UKS, 66421, Homburg/Saar, Deutschland
| | - N Szentmáry
- Dr. Rolf M. Schwiete Zentrum für Limbusstammzellforschung und kongenitale Aniridie, Universität des Saarlandes, Homburg/Saar, Deutschland
| | - A Langenbucher
- Institut für Experimentelle Ophthalmologie, Universität des Saarlandes, Homburg/Saar, Deutschland
| | - E Flockerzi
- Klinik für Augenheilkunde und Hochschulambulanz, Universitätsklinikum des Saarlandes UKS, 66421, Homburg/Saar, Deutschland
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[Partial visual rehabilitation 5 and 6 years after a Gundersen total conjunctival flap procedure]. Ophthalmologe 2021; 119:203-208. [PMID: 34581853 DOI: 10.1007/s00347-021-01503-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 08/17/2021] [Accepted: 08/25/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND We present the results of penetrating keratoplasty (PKP) after previous treatment with a total conjunctival flap in two patients. CASE REPORTS Patient 1, a 66-year-old with a history of bilateral cement chemical burn in 1986 and external right-sided limbokeratoplasty in 2008 was treated externally with a total conjunctival flap in the right eye in 2014 due to a persistent corneal ulcer with imminent perforation. Best-corrected visual acuity (BCVA) in the right eye was light sensation, intraocular pressure on palpation was within normal range. Clinically, total conjunctival flap was present. Patient 2 was treated externally in May 2015 due to acanthamoeba keratitis in the left eye with a deep anterior lamellar keratoplasty (DALK). A re-DALK was also performed externally in the same month. A third DALK was performed externally in August 2015 due to a persistent corneal ulcer, followed by a total conjunctival flap 2 weeks later. BCVA of the left eye was light sensation and intraocular pressure on palpation was within the normal range. RESULTS Patient 1 was treated with removal of the conjunctival flap in the right eye and penetrating central re-keratoplasty (hand-held Barron trephine; graft diameter 8.5/8.75 mm). Simultaneously, lens extraction and intraocular lens implantation were performed (as a triple procedure). Additionally, amniotic membrane transplantation (AMT) as patch and a temporal lateral tarsorrhaphy were performed. BCVA 6 months postoperatively was 0.1. The graft was clear, without any signs of rejection. Patient 2 was treated on the left eye with removal of the conjunctival flap and a penetrating central keratoplasty (hand-held Barron trephine; graft diameter 7.0/7.5 mm). An AMT as patch and a temporal lateral tarsorrhaphy were simultaneously performed. Cataract surgery was performed 3 months postoperatively and BCVA of the right eye was 0.1 thereafter. The graft was clear, without any signs of rejection. CONCLUSION The conjunctival flap is a treatment of last resort of the (almost) penetrated corneal ulcer, which is to be used only when a keratoplasty is technically impossible. Provided the eye structure and retinal function are preserved, partial visual rehabilitation can possibly be achieved through a PKP after excision of the conjunctival flap, even years after corneal blindness.
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Quintin A, Hamon L, Mäurer S, Langenbucher A, Seitz B. OCT Application for Sterile Corneal Graft Screening in the Eye Bank. Klin Monbl Augenheilkd 2021; 238:688-692. [PMID: 34157771 DOI: 10.1055/a-1443-5451] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND AND OBJECTIVE Sterile donor tomography enables the detection of corneal tissues with refractive anomalies. The aim of this study was to determine the curvature and thickness of donor corneas to support proper selection in the eye bank. METHODS 704 donor corneas (Klaus Faber Center, LIONS Eye Bank Saar-Lor-Lux, Trier/Westpfalz, in Homburg/Saar) were measured using the anterior segment optical coherence tomograph (AS-OCT) CASIA 2 (Tomey Corp., Nagoya, Japan). The corneoscleral discs were measured in their cell culture flask, which was positioned in a holder on the chin rest of the AS-OCT, after conversion to medium II (with 6% dextran T-500). The measured raw data were analysed and processed in MATLAB (MathWorks Inc., Natick, Massachusetts, USA), after which the refractive power of the steep and flat meridian at the anterior and posterior surface and the central corneal thickness (CCT) of the donor corneas were determined. Results values are expressed as mean x̅ ± standard deviation SD. RESULTS The mean refractive power of the steep/flat meridian at the anterior surface was 45.4 ± 1.8 D/44.0 ± 1.3 D, the corresponding values for the posterior surface were - 6.2 ± 0.3 D/- 5.9 ± 0.2 D, and the mean CCT was 616.3 ± 85.1 µm. Of the 704 (100%) measured donor tissues, 590 (83.8%)/670 (95.2%) donor corneas showed no anomaly beyond respectively x̅ ± 2 SD/x̅ ± 3 SD among the 5 examined parameters. 72 (10.3%)/23 (3.3%) donor corneas had only 1 anomaly, 26 (3.7%)/10 (1.4%) had 2 anomalies, 10 (1.4%)/1 (0.1%), 3 anomalies, 5 (0.7%)/0 (0.0%), 4 anomalies, and 1 (0.1%)/0 (0.0%), 5 anomalies. CONCLUSIONS AS-OCT provides an objective and sterile screening method to identify corneal tissues with curvature anomalies in order to further optimise donor selection in the eye bank. To avoid postoperative refractive surprises, donor corneas with a total refractive power that deviates > ± 3 SD from the mean should not be used for penetrating or anterior lamellar keratoplasty, but may be suitable for posterior lamellar keratoplasty (DMEK or DSAEK). In the future, sterile donor tomography could enable: (1) the harmonisation of donor and recipient tomography, which may minimise residual astigmatism for a particular donor-recipient pair; and (2) the improvement of IOL power calculation in a classical triple procedure by means of regression analysis between pre- and postoperative total refractive power of corneal grafts.
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Affiliation(s)
- Adrien Quintin
- Department of Ophthalmology, Saarland University Medical Center (UKS), Homburg/Saar, Germany
| | - Loïc Hamon
- Department of Ophthalmology, Saarland University Medical Center (UKS), Homburg/Saar, Germany
| | - Stephanie Mäurer
- Institute of Experimental Ophthalmology, Saarland University, Homburg/Saar, Germany
| | - Achim Langenbucher
- Institute of Experimental Ophthalmology, Saarland University, Homburg/Saar, Germany
| | - Berthold Seitz
- Department of Ophthalmology, Saarland University Medical Center (UKS), Homburg/Saar, Germany
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Yoon CH, Choi HJ, Kim MK. Corneal xenotransplantation: Where are we standing? Prog Retin Eye Res 2021; 80:100876. [PMID: 32755676 PMCID: PMC7396149 DOI: 10.1016/j.preteyeres.2020.100876] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 05/23/2020] [Accepted: 06/04/2020] [Indexed: 02/08/2023]
Abstract
The search for alternatives to allotransplants is driven by the shortage of corneal donors and is demanding because of the limitations of the alternatives. Indeed, current progress in genetically engineered (GE) pigs, the introduction of gene-editing technology by clustered regularly interspaced short palindromic repeats (CRISPR)-Cas9, and advanced immunosuppressants have made xenotransplantation a possible option for a human trial. Porcine corneal xenotransplantation is considered applicable because the eye is regarded as an immune-privileged site. Furthermore, recent non-human primate studies have shown long-term survival of porcine xenotransplants in keratoplasty. Herein, corneal immune privilege is briefly introduced, and xenogeneic reactions are compared with allogeneic reactions in corneal transplantation. This review describes the current knowledge on special issues of xenotransplantation, xenogeneic rejection mechanisms, current immunosuppressive regimens of corneal xenotransplantation, preclinical efficacy and safety data of corneal xenotransplantation, and updates of the regulatory framework to conduct a clinical trial on corneal xenotransplantation. We also discuss barriers that might prevent xenotransplantation from becoming common practice, such as ethical dilemmas, public concerns on xenotransplantation, and the possible risk of xenozoonosis. Given that the legal definition of decellularized porcine cornea (DPC) lies somewhere between a medical device and a xenotransplant, the preclinical efficacy and clinical trial data using DPC are included. The review finally provides perspectives on the current standpoint of corneal xenotransplantation in the fields of regenerative medicine.
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Affiliation(s)
- Chang Ho Yoon
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul, Republic of Korea; Laboratory of Ocular Regenerative Medicine and Immunology, Seoul Artificial Eye Center, Seoul National University Hospital Biomedical Research Institute, Seoul, Republic of Korea
| | - Hyuk Jin Choi
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul, Republic of Korea; Laboratory of Ocular Regenerative Medicine and Immunology, Seoul Artificial Eye Center, Seoul National University Hospital Biomedical Research Institute, Seoul, Republic of Korea; Department of Ophthalmology, Seoul National University Hospital Healthcare System Gangnam Center, Seoul, Republic of Korea
| | - Mee Kum Kim
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul, Republic of Korea; Laboratory of Ocular Regenerative Medicine and Immunology, Seoul Artificial Eye Center, Seoul National University Hospital Biomedical Research Institute, Seoul, Republic of Korea.
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22
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Yu AC, Myerscough J, Galante G, Furiosi L, Socea S, Bovone C, Busin M. Pneumatic Dissection for Large-Diameter (9-mm) Deep Anterior Lamellar Keratoplasty in Eyes With Previous Anterior Lamellar Keratoplasty. Cornea 2020; 40:1098-1103. [PMID: 33332898 DOI: 10.1097/ico.0000000000002609] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 10/02/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE To evaluate the surgical and 3-year clinical outcomes of modified big-bubble 9-mm deep anterior lamellar keratoplasty (DALK) in eyes with previous ALK (ALK). METHODS In this interventional case series, 21 consecutive eyes with unsatisfactory vision after ALK (superficial ALK n = 9; laser-assisted ALK n = 7; and epikeratophakia n = 5) underwent large-diameter (9-mm) DALK. The surgery involved deep trephination based on the anterior segment optical coherence tomography pachymetry measurement at 9-mm diameter, pneumatic dissection from the base of the trephination and limited stromal clearance of the optical zone (6 mm). Main outcome measures were success rates of pneumatic dissection, best spectacle-corrected visual acuity, and complication rates. RESULTS Pneumatic dissection with type 1 bubble formation succeeded in 19 (90%) eyes. In the 2 remaining cases, the 6-mm optical zone was cleared by manual dissection. Perforation occurred in one of the latter cases; no procedure was converted to penetrating keratoplasty. One month after complete suture removal, the preoperative mean best spectacle-corrected visual acuity (0.75 ± 0.23 logMAR) improved to 0.09 ± 0.10 logMAR (P < 0.001) and remained stable up to 3 years after surgery. At the final follow-up, refractive astigmatism was ≤4.5 and <6 D in 20 (95%) and 21 (100%) eyes, respectively. Stromal rejection was observed in 2 eyes (10%) and was treated successfully with steroids. CONCLUSIONS Even in eyes with previous ALK, pneumatic dissection can be achieved through a modified DALK technique with a low risk of complications and excellent visual and refractive outcomes.
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Affiliation(s)
- Angeli Christy Yu
- Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy.,Department of Ophthalmology, Ospedali Privati Forlì "Villa Igea," Forlì, Italy.,Istituto Internazionale per la Ricerca e Formazione in Oftalmologia, Forlì, Italy
| | - James Myerscough
- Department of Ophthalmology, Ospedali Privati Forlì "Villa Igea," Forlì, Italy.,Istituto Internazionale per la Ricerca e Formazione in Oftalmologia, Forlì, Italy.,Department of Ophthalmology, Southend University Hospital, Southend, United Kingdom; and
| | - Giuditta Galante
- Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy.,Department of Ophthalmology, Ospedali Privati Forlì "Villa Igea," Forlì, Italy.,Istituto Internazionale per la Ricerca e Formazione in Oftalmologia, Forlì, Italy
| | - Luca Furiosi
- Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy.,Department of Ophthalmology, Ospedali Privati Forlì "Villa Igea," Forlì, Italy.,Istituto Internazionale per la Ricerca e Formazione in Oftalmologia, Forlì, Italy
| | - Sergiu Socea
- Department of Ophthalmology, Ospedali Privati Forlì "Villa Igea," Forlì, Italy.,Istituto Internazionale per la Ricerca e Formazione in Oftalmologia, Forlì, Italy.,Department of Ophthalmology, Rambam Health Care Campus, Haifa, Israel
| | - Cristina Bovone
- Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy.,Department of Ophthalmology, Ospedali Privati Forlì "Villa Igea," Forlì, Italy.,Istituto Internazionale per la Ricerca e Formazione in Oftalmologia, Forlì, Italy
| | - Massimo Busin
- Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy.,Department of Ophthalmology, Ospedali Privati Forlì "Villa Igea," Forlì, Italy.,Istituto Internazionale per la Ricerca e Formazione in Oftalmologia, Forlì, Italy
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23
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Five-year Outcomes of Converted Mushroom Keratoplasty from Intended Deep Anterior Lamellar Keratoplasty (DALK) Mandate 9-mm Diameter DALK as the Optimal Approach to Keratoconus. Am J Ophthalmol 2020; 220:9-18. [PMID: 32681909 DOI: 10.1016/j.ajo.2020.07.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 07/02/2020] [Accepted: 07/03/2020] [Indexed: 12/18/2022]
Abstract
PURPOSE To compare the 5-year outcomes of 9-mm-deep anterior lamellar keratoplasty (DALK) for keratoconus with those of conversions to mushroom keratoplasty (MK). DESIGN Retrospective cohort study. METHODS The setting was the Ospedali Privati Villa Igea, Department of Ophthalmology, Forlì, Italy. The study population consisted of the medical records of all attempted DALK procedures (416 eyes) for the indication of keratoconus performed between January 2012 and January 2018; 68 eyes (16.4%) were converted to MK and analyzed as a separate cohort. The mean follow-up time was 33.8 ± 15.1 months. Procedure(s) consisted of 9-mm DALK and MK (9-mm anterior lamella with 6-mm posterior lamella). Outcome measurements were best-corrected visual acuity (BCVA), refractive astigmatism, and endothelial cell loss (ECL) at 5 years. RESULTS Average BCVA at 5 years was 0.06 ± 0.07 in the DALK group and 0.09 ± 0.15 in the MK group (P = .88). Refractive astigmatism following suture removal (all visits later than 12 months) was slightly less in the DALK cohort (5-year DALK = 2.16 ± 1.40 diopter [D]; MK = 3.02 ± 0.89 D; P = .04; mean difference = 0.86 D [95% confidence interval [CI]: 0.71-1.01]). ECL was significantly higher in the MK group than in the DALK group at all follow-up intervals (5-year DALK = 19.36 ± 21.47%; MK = 56.61 ± 15.82%; P < .001). The total all-cause graft failure rate at 5 years was 0.58% for DALK (2 of 348) cases and 5.88% for MK (4 of 68) cases. CONCLUSIONS Excellent 5-year visual and clinical outcomes associated with a 2-piece MK in cases converted from intended DALK mandate large-diameter DALK (9 mm) as the optimal surgical approach to keratoconus.
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Quintin A, Hamon L, Mäurer S, Langenbucher A, Seitz B. Vergleich der sterilen Spendertomographie in der Hornhautbank mit der Tomographie des Transplantates nach perforierender Keratoplastik. Ophthalmologe 2020; 118:1038-1044. [PMID: 33258059 PMCID: PMC8492567 DOI: 10.1007/s00347-020-01256-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 10/09/2020] [Accepted: 10/12/2020] [Indexed: 11/25/2022]
Abstract
Zusammenfassung
Hintergrund
Seit 2018 verwenden wir die sterile Spendertomographie in der Hornhautbank routinemäßig, um refraktive Überraschungen nach Keratoplastik zu vermeiden. Ziel dieser Studie war es, Spendertomographieparameter mit Tomographieparametern des Transplantates nach perforierender Keratoplastik (PKP) zu vergleichen.
Methoden
Diese Studie umfasste 193 Spendergewebe der Hornhautbank, die für eine PKP verwendet wurden (Transplantatdurchmesser 8,2 ± 0,7 mm). Messungen wurden mit dem optischen Kohärenztomographen des vorderen Augenabschnittes (VAA-OCT) Casia 2 (Tomey Corp., Nagoya, Japan) präoperativ sowie postoperativ nach 5 ± 4 Monaten bei liegenden Fäden und nach 22 ± 4 Monaten ohne Fäden durchgeführt. Post- und präoperative Werte wurden mithilfe des Wilcoxon-Rangsummentests verglichen.
Ergebnisse
Postoperativ, bei liegenden (bzw. ohne) Fäden, war die Brechkraft (P) der Hornhautvorderfläche (v) im steilen Meridian (S) (PvS) unverändert (−0,2 dpt; p = 0,78) (um 2,7 dpt größer [p < 0,01]) und im flachen Meridian (F) (PvF) um 4,5 dpt (2,8 dpt) niedriger (p < 0,01) im Vergleich zu den Spendertomographiewerten. Der Astigmatismus (v) war um 4,3 dpt (5,4 dpt) größer (p < 0,01). An der Rückfläche (r) war PrS um 0,9 dpt (0,9 dpt) und PrF um 0,3 dpt (p < 0,01) (0,1 dpt [p = 0,42]) kleiner, während der Astigmatismus (r) um 0,7 dpt (0,9 dpt) größer war (p < 0,01). Die zentrale Hornhautdicke war um 55,7 μm (p < 0,01) (27,5 µm [p = 0,01]) kleiner. Die Gesamtbrechkraft ohne Fäden änderte sich nicht signifikant im Vergleich zur Hornhautbankmessung.
Schlussfolgerung
Zentrale Hornhautdicke, Brechkraft (P) und Astigmatismus veränderten sich postoperativ im Vergleich zu den Spendertomographiewerten, mit Ausnahme von P im steilen Meridian der Vorderfläche bei liegenden Fäden sowie von P im flachen Meridian der Rückfläche nach Entfernung aller Fäden. Die Gesamtbrechkraft ohne Fäden ändert sich allerdings nicht signifikant. Diese Informationen könnten für eine Verbesserung der Kunstlinsenberechnung bei klassischer „Triple-Procedure“ von Bedeutung sein.
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Affiliation(s)
- A Quintin
- Klinik für Augenheilkunde, Universitätsklinikum des Saarlandes (UKS), Homburg/Saar, Deutschland.
| | - L Hamon
- Klinik für Augenheilkunde, Universitätsklinikum des Saarlandes (UKS), Homburg/Saar, Deutschland
| | - S Mäurer
- Institut für Experimentelle Ophthalmologie, Universität des Saarlandes, Homburg/Saar, Deutschland
| | - A Langenbucher
- Institut für Experimentelle Ophthalmologie, Universität des Saarlandes, Homburg/Saar, Deutschland
| | - B Seitz
- Klinik für Augenheilkunde, Universitätsklinikum des Saarlandes (UKS), Homburg/Saar, Deutschland
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25
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Alió Del Barrio JL, Bhogal M, Ang M, Ziaei M, Robbie S, Montesel A, Gore DM, Mehta JS, Alió JL. Corneal transplantation after failed grafts: Options and outcomes. Surv Ophthalmol 2020; 66:20-40. [PMID: 33065176 DOI: 10.1016/j.survophthal.2020.10.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 09/30/2020] [Accepted: 10/05/2020] [Indexed: 12/27/2022]
Abstract
Corneal transplantation is the most commonly performed human tissue transplantation procedure worldwide. Because of the large number of transplants, corneal graft failure has become one of the most common indications for corneal transplantation. The relatively recently developed lamellar transplant techniques have brought about specific potential complications leading to graft failure that may require different approaches to repeat transplantation other than penetrating keratoplasty. On the other hand, these new lamellar techniques also provide novel ways of rescuing failed penetrating grafts, with potential advantages over successive penetrating keratoplasties, such as reduced intraoperative risks and faster visual rehabilitation. We summarize the incidence and risk factors of graft failure for penetrating and lamellar (stromal and endothelial) corneal transplants and discuss the various surgical alternatives currently available to rescue such failed grafts, with a focus on the reported outcomes and limitations.
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Affiliation(s)
- Jorge L Alió Del Barrio
- Cornea, Cataract and Refractive Surgery Unit, Vissum (Miranza Group), Alicante, Spain; Division of Ophthalmology, Universidad Miguel Hernández, Alicante, Spain.
| | | | - Marcus Ang
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore; Department of Ophthalmology and Visual Science, Duke-NUS Graduate Medical School, Singapore
| | - Mohammed Ziaei
- Department of Ophthalmology, New Zealand National Eye Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Scott Robbie
- Cornea Unit, Guy's & St Thomas' Hospital, London, UK
| | - Andrea Montesel
- Cornea, Cataract and Refractive Surgery Unit, Vissum (Miranza Group), Alicante, Spain; Jules Gonin Eye Hospital, University of Lausanne, Lausanne, Switzerland
| | - Daniel M Gore
- External Disease Service, Moorfields Eye Hospital, London, UK
| | - Jodhbir S Mehta
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore; Department of Ophthalmology and Visual Science, Duke-NUS Graduate Medical School, Singapore
| | - Jorge L Alió
- Cornea, Cataract and Refractive Surgery Unit, Vissum (Miranza Group), Alicante, Spain; Division of Ophthalmology, Universidad Miguel Hernández, Alicante, Spain
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27
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8.5/8.6-mm Excimer Laser–Assisted Penetrating Keratoplasties in a Tertiary Corneal Subspecialty Referral Center: Indications and Outcomes in 107 Eyes. Cornea 2020; 39:806-811. [DOI: 10.1097/ico.0000000000002327] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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28
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Pradhan KR, Reinstein DZ, Vida RS, Archer TJ, Dhungel S, Dhungana P, Carp GI. Femtosecond Laser-Assisted Small Incision Sutureless Intrastromal Lamellar Keratoplasty (SILK) for Corneal Transplantation in Keratoconus. J Refract Surg 2020; 35:663-671. [PMID: 31610008 DOI: 10.3928/1081597x-20190826-01] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 08/26/2019] [Indexed: 11/20/2022]
Abstract
PURPOSE To describe a femtosecond laser-assisted small incision sutureless intrastromal lamellar keratoplasty in an eye with severe keratoconus and report on the outcome with a 1-year follow-up. METHODS A 20-year-old man with a history of keratoconus presented for evaluation at the Tilganga Institute of Ophthalmology, Kathmandu, Nepal. The patient had previously undergone a deep anterior lamellar keratoplasty in the left eye. Examination of the right eye revealed an uncorrected distance visual acuity (UDVA) of counting fingers with a manifest refraction of -5.00 -3.50 × 170, giving a corrected distance visual acuity (CDVA) of 20/80. Thinnest pachymetry was 425 µm and progression of both anterior and posterior corneal elevation tomography and maximum keratometry was noted compared to examination 2 years prior. The VisuMax femtosecond laser (Carl Zeiss Meditec, Jena, Germany) was used to prepare the donor and recipient cornea. The donor graft was inserted into the recipient through the 3-mm small incision. No sutures were applied. RESULTS At 2 weeks postoperatively, UDVA was 20/50 with a manifest refraction of -1.00 -5.00 × 145 (20/32). One year postoperatively, UDVA was 20/80 with a manifest refraction of -2.50 -3.50 × 125 (20/40-2), with the maximum keratometry decreasing from 64.08 to 56.74 diopters. CONCLUSIONS This femtosecond laser-assisted sutureless intrastromal corneal transplantation technique may provide an option to improve the quality of vision for some patients with keratoconus, affording a simpler postoperative follow-up course compared to traditional anterior lamellar or full-thickness corneal transplantation. [J Refract Surg. 2019;35(10):663-671.].
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Boden KT, Schlosser R, Boden K, Januschowski K, Szurman P, Rickmann A. Novel Liquid Interface for Femtosecond Laser-Assisted Penetrating Keratoplasty. Curr Eye Res 2020; 45:1051-1057. [DOI: 10.1080/02713683.2020.1716985] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
| | | | - Katrin Boden
- Eye Clinic Sulzbach, Knappschaft Hospital Saar, Sulzbach, Germany
| | - Kai Januschowski
- Eye Clinic Sulzbach, Knappschaft Hospital Saar, Sulzbach, Germany
- Centre for Ophthalmology, University Eye Hospital Tuebingen, Tuebingen, Germany
| | - Peter Szurman
- Eye Clinic Sulzbach, Knappschaft Hospital Saar, Sulzbach, Germany
- Centre for Ophthalmology, University Eye Hospital Tuebingen, Tuebingen, Germany
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30
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Scorcia V, Giannaccare G, Logozzo L, Soda M. Keratoconus: advances in anterior lamellar keratoplasty techniques. EXPERT REVIEW OF OPHTHALMOLOGY 2020. [DOI: 10.1080/17469899.2020.1728687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Vincenzo Scorcia
- From Department of Ophthalmology, University Magna Graecia, Catanzaro, Italy
| | | | - Laura Logozzo
- From Department of Ophthalmology, University Magna Graecia, Catanzaro, Italy
| | - Mauro Soda
- From Department of Ophthalmology, University Magna Graecia, Catanzaro, Italy
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31
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Seitz B, Daas L, Milioti G, Szentmàry N, Langenbucher A, Suffo S. Excimerlaser-assistierte perforierende Keratoplastik. Ophthalmologe 2019; 116:1221-1230. [DOI: 10.1007/s00347-019-00990-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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32
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Elkamshoushy A, Gonnah R, Madi S, Beltz J. Single-piece femtosecond-assisted mushroom keratoplasty in children. J AAPOS 2019; 23:28.e1-28.e5. [PMID: 30500436 DOI: 10.1016/j.jaapos.2018.08.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Revised: 08/13/2018] [Accepted: 08/19/2018] [Indexed: 12/13/2022]
Abstract
PURPOSE To report outcomes of femtosecond-assisted single-piece mushroom keratoplasty for the treatment of full-thickness corneal disease in pediatric patients with healthy endothelium. METHODS Femtosecond-assisted mushroom keratoplasty was performed in 8 eyes of 8 patients (age range, 8-17 years) with central full-thickness corneal opacity. The single-piece mushroom-shaped graft consisted of a large anterior portion (9 mm in diameter; 250 μm in thickness) and a small posterior portion (6-6.5 mm). Donor and recipient corneas were prepared using the WaveLight FS200 laser (Alcon Laboratories, Fort Worth, TX). The donor cornea was oversized by 0.2 mm. Outcome measures were best spectacle-corrected visual acuity, spectacle refraction, topographic astigmatism, endothelial cell density, graft rejection, and graft failure at 1, 3, 6, and 12 months. RESULTS Mean best spectacle-corrected visual acuity at 1, 3, 6, and 12 months was 0.28, 0.16, 0.13, and 0.10 logMAR; all patients achieved logMAR of at least 0.4 at 1, 3, 6, and 12 months. The mean refractive cylinder was 2.6 D, and mean endothelial cell loss was 13.3% at 12 months postoperatively. Two eyes had immunologic rejection episodes that were reversed with topical steroids. All corneas remained clear at final follow-up. CONCLUSIONS Femtosecond-assisted mushroom keratoplasty is a viable surgical option for eyes of older pediatric patients with full-thickness corneal stromal disease and healthy endothelium. Mushroom keratoplasty combines the refractive advantage of a large keratoplasty with the immunologic advantage of a small keratoplasty. Single-piece femtosecond-assisted mushroom keratoplasty may have a mechanical advantage over regular penetrating keratoplasty.
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Affiliation(s)
- Amr Elkamshoushy
- Ophthalmology Department, Alexandria University, Alexandria, Egypt
| | - Reem Gonnah
- Ophthalmology Department, Alexandria University, Alexandria, Egypt
| | - Silvana Madi
- Ophthalmology Department, Alexandria University, Alexandria, Egypt.
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33
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Deep Trephination Allows High Rates of Successful Pneumatic Dissection for DALK Independent of Surgical Experience. Cornea 2019; 38:645-647. [DOI: 10.1097/ico.0000000000001881] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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34
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Immunologic Stromal Rejection After Deep Anterior Lamellar Keratoplasty With Grafts of a Larger Size (9 mm) for Various Stromal Diseases. Cornea 2018. [PMID: 29543665 DOI: 10.1097/ico.0000000000001584] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To evaluate the rate and outcomes of immunologic stromal rejection occurring after large deep anterior lamellar keratoplasty (DALK) and the effect of the underlying disease on the cumulative probability of rejection. METHODS This was a retrospective chart review of all eyes that underwent a 9-mm DALK at Ospedali Privati Forlì (Forlì, Italy). On the basis of preoperative diagnosis, eyes were assigned to group 1: keratoconus, group 2: stromal disease with a low risk for rejection, or group 3: stromal disease with a high risk for rejection. The cumulative probability of experiencing a rejection episode over time was assessed by Kaplan-Meier analysis and was compared among the 3 groups using the log-rank test. Values of corrected distance visual acuity, central corneal thickness, and endothelial cell density before and 6 months after rejection were compared. RESULTS Twenty of 377 eyes (5.3%) experienced an episode of stromal rejection [17/265 (6.4%) in group 1, 2/71 (2.8%) in group 2, and 1/41 (2.4%) in group 3]. The mean time interval between DALK and the rejection onset was 11.8 months (range 1-24). The cumulative probability of rejection episodes did not differ significantly among the 3 groups. All episodes resolved within 6 months after the onset, with no significant differences between prerejection and 6-month postrejection values of corrected distance visual acuity, central corneal thickness, and endothelial cell density. CONCLUSIONS The rate of immunologic stromal rejection after large 9-mm DALK is within the range reported in the literature for conventional DALK, regardless of the indication for surgery.
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Ho Wang Yin G, Hoffart L. Post-keratoplasty astigmatism management by relaxing incisions: a systematic review. EYE AND VISION 2017; 4:29. [PMID: 29238735 PMCID: PMC5725940 DOI: 10.1186/s40662-017-0093-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Accepted: 11/26/2017] [Indexed: 12/02/2022]
Abstract
Postoperative visual acuity can be limited by post-keratoplasty astigmatism, even with a clear corneal graft. Astigmatism management can be performed by selective suture removal, adjustment of sutures, optical correction, photorefractive procedures, wedge resection, intra-ocular lens implantation, intracorneal ring segments, relaxing incisions with or without compression sutures and repeated keratoplasty. Relaxing incisions can be made in the graft, graft-host interface or host cornea. Despite the unpredictability of the method because the flat and steep meridians are usually not orthogonal after penetrating keratoplasty, with asymmetric power distribution, all the studies showed an overall reduction of refractive, keratometric or topographic astigmatism, ranging from 30% to 72% with manual or femtosecond-assisted techniques. Most patients with astigmatism higher than 6 diopters had residual cylinder less than or equal to 3 diopters, which can be treated by laser excimer ablation or secondary intraocular lens implantation.
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Affiliation(s)
- Gaëlle Ho Wang Yin
- Ophthalmology Department, Aix-Marseille University - APHM, Hôpital de la Timone, 264 rue Saint Pierre, 13 385 Marseille Cedex 5, France.,Institut Fresnel UMR 7249, Aix Marseille Université, CNRS, Centrale Marseille, Domaine universitaire de Saint-Jérôme Avenue Escadrille Normandie Niemen, 13397 Marseille cedex 20, France.,CERIMED, Aix-Marseille University, 27 Boulevard Jean-Moulin, 13385 Marseille cedex 05, France
| | - Louis Hoffart
- Ophthalmology Department, Aix-Marseille University - APHM, Hôpital de la Timone, 264 rue Saint Pierre, 13 385 Marseille Cedex 5, France.,Ramsay Générale de Santé, Clinique Monticelli-Velodrome, Marseille, France
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36
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Vitreous cavity length in keratoconus: implications for keratoplasty. Eye (Lond) 2017; 32:359-363. [PMID: 28885609 DOI: 10.1038/eye.2017.184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 05/04/2017] [Indexed: 11/08/2022] Open
Abstract
PurposeTo compare axial length (AL) with vitreous cavity length (VCL) in patients with keratoconus and to ascertain whether graft size can be tailored to reduce myopic refractive error in patients with keratoconus undergoing penetrating keratoplasty (PK).Patients and methodsThe AL and VCL were measured prospectively in patients with keratoconus not undergoing PK (Group 1) and in normal phakic, emmetropic individuals (Group 2). A retrospective analysis of these measurements in patients with keratoconus who had undergone PK (Group 3) was also performed. The postoperative spherical equivalent (SE) was then correlated to size of donor buttons.ResultsKeratoconus patients tended to have a longer mean VCL than emmetropic normal individuals. The mean VCL of these patients (Group 1) was 16.49 mm±SD 1.13 compared to the mean VCL of 15.94 mm±SD 0.56 in normals (Group 2, P<0.0001). Patients with keratoconus who had an undersized graft showed reduced myopic refractive error compared to those with same size or oversized grafts.ConclusionVCL measurement is more accurate than AL measurement in deciding upon graft-host size disparity for corneal graft in patients with keratoconus. In patients with increased VCL, undersizing the donor button helps in reducing postoperative myopia. We recommend VCL measurement as part of the routine workup in all keratoconus patients undergoing corneal transplants.
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Seitz B, Langenbucher A, Hager T, Janunts E, El-Husseiny M, Szentmáry N. Penetrating Keratoplasty for Keratoconus - Excimer Versus Femtosecond Laser Trephination. Open Ophthalmol J 2017; 11:225-240. [PMID: 28932339 PMCID: PMC5585536 DOI: 10.2174/1874364101711010225] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 04/29/2017] [Accepted: 06/13/2017] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND In case of keratoconus, rigid gas-permeable contact lenses as the correction method of first choice allow for a good visual acuity for quite some time. In a severe stage of the disease with major cone-shaped protrusion of the cornea, even specially designed keratoconus contact lenses are no more tolerated. In case of existing contraindications for intrastromal ring segments, corneal transplantation typically has a very good prognosis. METHODS In case of advanced keratoconus - especially after corneal hydrops due to rupture of Descemet's membrane - penetrating keratoplasty (PKP) still is the surgical method of first choice. Noncontact excimer laser trephination seems to be especially beneficial for eyes with iatrogenic keratectasia after LASIK and those with repeat grafts in case of "keratoconus recurrences" due to small grafts with thin host cornea. For donor trephination from the epithelial side, an artificial chamber is used. Wound closure is achieved with a double running cross-stitch suture according to Hoffmann. Graft size is adapted individually depending on corneal size ("as large as possible - as small as necessary"). Limbal centration will be preferred intraoperatively due to optical displacement of the pupil. During the last 10 years femtosecond laser trephination has been introduced from the USA as a potentially advantageous approach. RESULTS Prospective clinical studies have shown that the technique of non-contact excimer laser PKP improves donor and recipient centration, reduces "vertical tilt" and "horizontal torsion" of the graft in the recipient bed, thus resulting in significantly less "all-sutures-out" keratometric astigmatism (2.8 vs. 5.7 D), higher regularity of the topography (SRI 0.80 vs. 0.98) and better visual acuity (0.80 vs. 0.63) in contrast to the motor trephine. The stage of the disease does not influence functional outcome after excimer laser PKP. Refractive outcomes of femtosecond laser keratoplasty, however, resemble that of the motor trephine. CONCLUSIONS In contrast to the undisputed clinical advantages of excimer laser keratoplasty with orientation teeth/notches in keratoconus, the major disadvantage of femtosecond laser application is still the necessity of suction and applanation of the cone during trephination with intraoperative pitfalls and high postoperative astigmatism.
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Affiliation(s)
- Berthold Seitz
- Department of Ophthalmology, Saarland University Medical Center UKS, Homburg/Saar, Germany
| | - Achim Langenbucher
- Institute of Experimental Ophthalmology, University of Saarland, Homburg/Saar, Germany
| | - Tobias Hager
- Department of Ophthalmology, Saarland University Medical Center UKS, Homburg/Saar, Germany
| | - Edgar Janunts
- Institute of Experimental Ophthalmology, University of Saarland, Homburg/Saar, Germany
| | - Moatasem El-Husseiny
- Department of Ophthalmology, Saarland University Medical Center UKS, Homburg/Saar, Germany
| | - Nora Szentmáry
- Department of Ophthalmology, Saarland University Medical Center UKS, Homburg/Saar, Germany
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Large (9 mm) Deep Anterior Lamellar Keratoplasty with Clearance of a 6-mm Optical Zone Optimizes Outcomes of Keratoconus Surgery. Ophthalmology 2017; 124:1072-1080. [DOI: 10.1016/j.ophtha.2017.02.011] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Revised: 01/30/2017] [Accepted: 02/09/2017] [Indexed: 11/20/2022] Open
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Kolawole OA, Pillay V, Choonara YE. Novel Polyamide 6,10 Variants Synthesized by Modified Interfacial Polymerization for Application as a Rate-Modulated Monolithic Drug Delivery System. J BIOACT COMPAT POL 2016. [DOI: 10.1177/0883911507078269] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The aim of this study was to explore and elucidate the possibility of employing an aliphatic polyamide 6,10 (PA 6,10) synthesized by a modified interfacial polymerization process as a novel rate-modulated monolithic matrix drug delivery system. A Plackett—Burman experimental design was used to synthesize 14 different PA 6,10 polymers using the interfacial polymerization process of synthesis comprising the monomers namely hexamethylenediamine and sebacoyl chloride and the solvents namely hexane (nonpolar phase) and deionized water (polar phase). This process was modified by variations in stoichiometry of monomers, volume ratios of solvents as well as solvent phase modification using cyclohexane and sodium hydroxide for the nonpolar and polar solvent phases, respectively. The micromechanical parameters of the newly synthesized PA 6,10 variants were elucidated in terms of the matrix resilience (MR), matrix hardness and deformation energy, in which case matrix hardness and deformation energy were expressed as second-order polynomial hydration rate constants. The effect of changes in pH of the hydration media on these parameters was also explored as part of the characterization process. Scanning electron microscopy and Fourier transform infrared spectroscopy were used to correlate the effect of synthesis variables on the micromechanical behavior PA 6,10 and its subsequent ability to impact drug release. The micromechanical values revealed that all independent formulation variables had a significant influence on the responses. Furthermore, the applied statistical model was utilized in selecting a combination of reaction variables to produce optional physicomechanical properties. The MR was selected for optimization among other parameters since it had a prominent effect on matrix integrity as well as drug release. The one-way analysis of variance, comparison of experimental versus fitted data, the R2 and P-values as well as the Durbin—Watson statistic indices were used in ascertaining the accuracy of the model. The rate-modulating drug release ability of synthetic aliphatic PA 6,10 was explored to direct the optimization using a higher resolution Box—Behnken statistical design. Constraints were set to obtain levels of independent variables that optimized the physicomechanical properties and the mean dissolution time fixed at eight hours.
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Affiliation(s)
- Oluwatoyin A. Kolawole
- Department of Pharmacy and Pharmacology, Faculty of Health Sciences, University of the Witwatersrand, 7 York Road, Parktown 2193, Johannesburg, South Africa
| | - Viness Pillay
- Department of Pharmacy and Pharmacology, Faculty of Health Sciences, University of the Witwatersrand, 7 York Road, Parktown 2193, Johannesburg, South Africa,
| | - Yahya E. Choonara
- Department of Pharmacy and Pharmacology, Faculty of Health Sciences, University of the Witwatersrand, 7 York Road, Parktown 2193, Johannesburg, South Africa
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Abstract
BACKGROUND In cases of contact lens intolerance and/or central corneal scars, corneal transplantation is indicated for advanced keratoconus. This can be performed as deep anterior lamellar keratoplasty (DALK) or as penetrating keratoplasty (PKP). The German keratoplasty registry shows that the proportion of anterior lamellar grafts in Germany has remained stable at approximately 5 % in recent years. METHODS Up to now DALK has not been technically standardized but can result in a good visual acuity using the big bubble technique if Descemet's membrane is laid bare intraoperatively. In 10-20 % a conversion to PKP is required if perforation of Descemet's membrane occurs. In cases of advanced keratoconus PKP is still the method of first choice especially after corneal hydrops due to rupture of Descemet's membrane. Non-contact excimer laser trephination seems to be especially beneficial for eyes with iatrogenic keratectasia after LASIK and those with repeat grafts in cases of keratoconus recurrence due to the graft being too small. For donor trephination from the epithelial side, an artificial chamber is used. Wound closure is achieved by a double running cross-stitch suture according to Hoffmann. Graft size is adapted individually depending on corneal size (as large as possible and as small as necessary). Limbal centration is given priority intraoperatively due to optical displacement of the pupil. RESULTS Prospective clinical studies have shown that the technique of non-contact excimer laser PKP improves donor and recipient centration, reduces vertical tilt and horizontal torsion of the graft in the recipient bed, thus resulting in significantly less all-sutures-out keratometric astigmatism (2.8 D versus 5.7 D), higher regularity of the topography (SRI 0.80 vs. 0.98) and better visual acuity (0.80 vs. 0.63) in contrast to the motor trephine. The stage of the disease does not influence functional outcome after excimer laser PKP. CONCLUSIONS In cases with optimal course DALK achieves the same visual outcome as mechanical PKP but the healthy endothelium can be preserved and endothelial immune reactions are prevented in keratoconus. In contrast to the undisputed clinical advantages of excimer laser keratoplasty with orientation teeth/notches in keratoconus, the major disadvantage of femtosecond laser application is still the necessity of suction and applanation of the cone during trephination.
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Nanavaty MA, Wang X, Shortt AJ. Endothelial keratoplasty versus penetrating keratoplasty for Fuchs endothelial dystrophy. Cochrane Database Syst Rev 2014; 2:CD008420. [PMID: 24526345 PMCID: PMC4260402 DOI: 10.1002/14651858.cd008420.pub3] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Fuchs endothelial dystrophy (FED) is a condition in which there is premature degeneration of corneal endothelial cells. When the number of endothelial cells is reduced to a significant degree, fluid begins to accumulate within the cornea. As a result, the cornea loses its transparency and the individual suffers a reduction in vision. The only successful surgical treatment for this condition is replacement of part or all of the cornea with healthy tissue from a donor. The established procedure, penetrating keratoplasty (PKP), has been used for many years and its safety and efficacy are well known. Endothelial keratoplasty (EK) techniques are relatively new surgical procedures and their safety and efficacy relative to PKP are uncertain. OBJECTIVES The objective of this review was to compare the benefits and complications related to two surgical methods (EK and PKP) of replacing the diseased endothelial layer of the cornea with a healthy layer in people with FED. SEARCH METHODS We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2014, Issue 1), MEDLINE (January 1950 to January 2014), EMBASE (January 1980 to January 2014), Latin American and Caribbean Health Sciences Literature Database (LILACS) (January 1982 to January 2014), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com) and ClinicalTrials.gov (www.clinicaltrials.gov). There were no date or language restrictions in the electronic searches for trials. The electronic databases were last searched on 27 January 2014. SELECTION CRITERIA We included all randomised controlled trials (RCTs) comparing EK versus PKP for people (of any age and gender) who had been clinically diagnosed with FED. DATA COLLECTION AND ANALYSIS Two authors independently screened the search results, assessed trial quality and extracted data using the standard methodological procedures expected by The Cochrane Collaboration. MAIN RESULTS We included three RCTs that enrolled a total of 139 eyes of 136 participants and analysed 123 (88%) eyes. Two RCTs randomised eyes into either the endothelial keratoplasty (EK) group or penetrating keratoplasty (PKP) group and one RCT randomised eyes into either the femtosecond laser-assisted endothelial keratoplasty (FLEK) group or PKP group. The RCTs comparing EK with PKP did not show any significant differences between procedures with respect to best corrected visual acuity (BCVA) at two years (mean difference (MD) 0.14 logMAR; 95% confidence interval (CI) -0.08 to 0.36; P = 0.23) or at one year (MD 0.09 logMAR; 95% CI -0.05 to 0.23; P = 0.22), whereas the trial comparing FLEK with PKP showed significantly better BCVA after PKP (MD 0.20 logMAR; 95% CI 0.10 to 0.30; P = 0.0001). Only one RCT reported on irregular astigmatism (higher-order aberration), which was less with EK than PKP (MD -1.20 µm; 95% CI -1.53 to -0.87; P < 0.001). Only one RCT reported on endothelial cell counts (lower after FLEK than PKP: MD -969 cells/mm²; 95% CI -1161 to -777; P < 0.001), primary graft failure (higher after FLEK than PKP: RR 7.76; 95% CI 0.41 to 145.22; P = 0.10), and graft rejection (more after FLEK than PKP: RR 1.11; 95% CI 0.07 to 17.12; P = 0.94). Only one RCT reported that 27.8% of participants had graft dislocation, 2.8% had epithelial ingrowth and postoperative pupillary block, and 13.9% had intraocular pressure (IOP)-related problems in the FLEK group compared with the PKP group, in whom 10% had suture-related problems, 5% had wound dehiscence and 10% had suture revision to correct astigmatism. Overall, the adverse events in the FLEK group appeared to be more frequent than in the PKP group. No trials reported information about quality of life or economic data. The overall methodological quality of the three trials was not satisfactory as most did not perform allocation concealment or masking of participants and outcome assessors, and all trials had a small sample size. AUTHORS' CONCLUSIONS The rapid growth of endothelial keratoplasty as the treatment of choice for FED is based upon the belief that visual recovery is more rapid, surgically induced astigmatism (regular and irregular) is less and rates of transplant rejection are lower with EK. This change in practice also assumes that the rates of long term transplant survival are equal for the two procedures. The practical differences between the surgical procedures mean that visual recovery is inherently more rapid following EK, but this review found no strong evidence from RCTs of any difference in the final visual outcome between EK and PKP for people with FED. This review also found that higher order aberrations are fewer following EK but endothelial cell loss is greater following EK. The RCTs that we included employed different EK techniques, which may have a bearing on these findings. EK procedures have evolved over the years and can be performed using different techniques, for example deep lamellar endothelial keratoplasty, Descemets stripping endothelial keratoplasty (DSEK), Descemets stripping automated endothelial keratoplasty (DSAEK), femtosecond laser-assisted endothelial keratoplasty and Descemet membrane endothelial keratoplasty (DMEK). More RCTs are needed to compare PKP with commonly performed EK procedures such as DSEK, DSAEK and DMEK in order to determine the answers to two key questions, whether there is any difference in the final visual outcome between these techniques and whether there are differences in the rates of graft survival in the long term?
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Affiliation(s)
- Mayank A Nanavaty
- Sussex Eye Hospital, Brighton & Sussex University
Hospitals NHS Trust, Brighton, UK
| | - Xue Wang
- Department of Epidemiology, Johns Hopkins Bloomberg School
of Public Health, Baltimore, Maryland, USA
| | - Alex J Shortt
- The Moorfields Eye Hospital/UCL Institute of Ophthalmology
National Institute for Health Research Biomedical Research Centre, London, UK
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Helaly H, Goweida M. Influence of surgical factors on postoperative corneal refractive power and astigmatism after keratoplasty. JOURNAL OF THE EGYPTIAN OPHTHALMOLOGICAL SOCIETY 2014. [DOI: 10.4103/2090-0686.150682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Borderie VM, Georgeon C, Borderie M, Bouheraoua N, Touzeau O, Laroche L. Corneal radius of curvature after anterior lamellar versus penetrating keratoplasty. Graefes Arch Clin Exp Ophthalmol 2013; 252:449-56. [DOI: 10.1007/s00417-013-2545-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Revised: 11/24/2013] [Accepted: 11/29/2013] [Indexed: 11/24/2022] Open
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Adeleke OA, Choonara YE, Kumar P, du Toit LC, Tomar LK, Tyagi C, Pillay V. Evaluation of the impacts of formulation variables and excipients on the drug release dynamics of a polyamide 6,10-based monolithic matrix using mathematical tools. AAPS PharmSciTech 2013; 14:1349-59. [PMID: 23990121 DOI: 10.1208/s12249-013-0021-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Accepted: 08/05/2013] [Indexed: 11/30/2022] Open
Abstract
Drug release from hydrophilic matrices is regulated mainly by polymeric erosion, disentanglement, dissolution, swelling front movement, drug dissolution and diffusion through the polymeric matrix. These processes depend upon the interaction between the dissolution media, polymeric matrix and drug molecules, which can be significantly influenced by formulation variables and excipients. This study utilized mathematical parameters to evaluate the impacts of selected formulation variables and various excipients on the release performance of hydrophilic polyamide 6,10 (PA 6,10) monolithic matrix. Amitriptyline HCl and theophylline were employed as the high and low solubility model drugs, respectively. The incorporation of different excipient concentrations and changes in formulation components influenced the drug release dynamics as evidenced by computed mathematical quantities (t x%, MDT x%, f 1, f 2, k 1, k 2, and К F). The effects of excipients on drug release from the PA 6,10 monolithic matrix was further elucidated using static lattice atomistic simulations wherein the component energy refinements corroborates the in vitro and in silico experimental data. Consequently, the feasibility of modulating release kinetics of drug molecules from the novel PA 6,10 monolithic matrix was well suggested.
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Fejza A, Schafia A, Löw U, Hille K, Seitz B. [Visual acuity and astigmatism after keratoplasty. Differences between the guided trephine system and motor trephine]. Ophthalmologe 2013; 110:464-9. [PMID: 23404224 DOI: 10.1007/s00347-012-2776-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND The purpose of this study was to assess the differences in postoperative visual acuity, astigmatism, and selected postoperative complications between a guided trephine system (GTS) and motor trephine after penetrating keratoplasty. PATIENTS AND METHODS In this retrospective analysis 74 patients who had undergone penetrating keratoplasty either by GTS (n = 53) or by motor trephine (Motortrepan) (n = 21) were included. Both patient groups included in this analysis were selected to ensure a homogeneous distribution of preoperative parameters to the greatest possible extent. However, some significant differences in patient selection between the two groups could not be avoided. Patients in the motor trephine group were older (mean age 68.4 years vs 56.4 years; p < 0.01) and had Fuchs' endothelial dystrophy more often (47.6 % vs 26.4 %) and significantly less keratoconus (14.3 % vs 32.1 %). RESULTS No significant differences regarding visual acuity outcomes could be found between GTS and Motortrepan. In both patient groups there were no differences in the amount of preoperative astigmatism (1.36 vs. 2.0 dpt., p = 0.39). However, at the time of final corneal suture removal (2.23 vs. 3.5 dpt., p = 0.03) and at a postoperative control 1 year after final suture removal (2.29 vs. 3.85 dpt., p = 0.005) the amount of astigmatism in the motor trephine group was found to be significantly higher. CONCLUSION In summary penetrating kerastoplasty using the motor trephine was found to result in significantly higher postoperative astigmatism than those performed with the GTS.
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Affiliation(s)
- A Fejza
- Klinik für Augenheilkunde, Universitätsklinikum des Saarlandes, Homburg/Saar.
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Seitz B, Langenbucher A, Naumann GOH. [Perspectives of excimer laser-assisted keratoplasty]. Ophthalmologe 2012; 108:817-24. [PMID: 21909869 DOI: 10.1007/s00347-011-2333-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND PURPOSE The purpose of this paper is to demonstrate the evolution of laser keratoplasty and to outline the potential future perspectives of this technique. METHODS For non-contact donor trephination from the epithelial side an artificial anterior chamber has been used. Since 1989 more than 3,300 penetrating keratoplasty operations (PKP) have been performed successfully with the Zeiss-Meditec MEL60® excimer laser in Erlangen and Homburg/Saar. RESULTS Prospective clinical studies have shown that the technique of non-contact excimer laser PKP improves donor and recipient decentration, reduces vertical tilt and horizontal torsion of the graft in the recipient bed, thus resulting in significantly less all-sutures-out keratometric astigmatism, higher regularity of the topography and better visual acuity. Besides less blood-aqueous barrier breakdown during the early postoperative course after PKP, excimer laser trephination does not induce cataract formation and does not impair the graft endothelium. Likewise, the rate of immunological graft rejections is not adversely affected by the excimer laser. In addition, trephination of an instable cornea is facilitated. CONCLUSIONS Because of undisputed clinical advantages, especially in eyes with keratoconus, excimer laser trephination with orientation teeth/notches is still favored in Homburg/Saar in daily practice. The femtosecond laser (FSL)-assisted keratoplasty technique is very exciting but a prospective randomized study is required to determine potential benefits over excimer laser PKP.
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Affiliation(s)
- B Seitz
- Klinik für Augenheilkunde, Universitätsklinikum des Saarlandes UKS, Kirrbergerstr., 66421, Homburg/Saar, Deutschland.
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Sung MS, Oh HJ, Yoon KC. Changes in Higher-Order Aberrations after Penetrating Keratoplasty. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2012. [DOI: 10.3341/jkos.2012.53.8.1088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Mi Sun Sung
- Department of Ophthalmology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Han Jin Oh
- Department of Ophthalmology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Kyung Chul Yoon
- Department of Ophthalmology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
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Nanavaty MA, Shortt AJ. Endothelial keratoplasty versus penetrating keratoplasty for Fuchs endothelial dystrophy. Cochrane Database Syst Rev 2011:CD008420. [PMID: 21735430 DOI: 10.1002/14651858.cd008420.pub2] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Fuchs endothelial dystrophy (FED), first described by Ernst Fuchsis in 1910, is a condition in which there is premature degeneration of corneal endothelial cells. When the number of endothelial cells is reduced to a significant degree fluid begins to accumulate within the cornea. As a result the cornea loses its transparency and the individual suffers a reduction in vision. The only successful surgical treatment for this condition is replacement of part or all of the cornea with healthy tissue from a cadaveric donor. The established procedure, penetrating keratoplasty (PKP), has been used for many years and its safety and efficacy are well known. Endothelial keratoplasty (EK) is a relatively new surgical procedure and the safety and efficacy relative to PKP are unknown. OBJECTIVES The objective of this review is to collate information on the benefits and complications related to two surgical methods (PKP and EK) of replacing the diseased endothelial layer of the cornea with a healthy layer in people with FED. SEARCH STRATEGY We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2011, Issue 2), MEDLINE (January 1950 to February 2011), EMBASE (January 1980 to February 2011), Latin American and Caribbean Health Sciences Literature Database (LILACS) (January 1982 to February 2011), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com) and ClinicalTrials.gov (www.clinicaltrials.gov). There were no date or language restrictions in the electronic searches for trials. The electronic databases were last searched on 6 February 2011. SELECTION CRITERIA We included all randomised controlled trials (RCTs) comparing EK versus PKP for people (of any age and gender) who had been clinically diagnosed with FED. When assessing the primary and secondary outcome measures, only RCTs were included in the analysis. As per our protocol a description of data from non-randomised comparative studies is also reported. As RCTs may not detect differences in frequency of adverse events, when assessing these we included data from cohort studies with more than 50 participants and a follow-up of up to five years. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial quality and extracted data. MAIN RESULTS The electronic searches identified one RCT, five non-randomised comparative studies and 34 cohort studies with a sample size of over 50 participants for inclusion. The RCT was conducted in the USA and included 28 eyes of 25 participants with FED. Although this is a very good RCT, there may be potential for bias due to lack of masking of assessors and possible selective reporting not being clearly reported. In this RCT, comparing EK versus PKP, best corrected visual acuity (BCVA) was similar at 24 months (PKP 0.20 ± 0.20 logMAR; EK 0.34 ± 0.35 logMAR; P = 0.23) and higher order aberrations (HOAs) (deviations of the performance of an optical system from the predictions of paraxial optics) were lower with EK. No other data were reported by the trial. Based on data obtained from both non-randomised comparative studies and individual cohort studies the endothelial rejection rate was between 5.3% and 23.2% for PKP and 2% and 4% for EK. However the mean follow-up duration in the EK cohort studies was noticeably shorter. The rate of EK graft dislocation requiring repositioning ranged from 3% to 63%, with the majority of studies having a rate of < 10%. AUTHORS' CONCLUSIONS There is no high quality evidence that EK is superior to PKP in the treatment of FED considering the studies that satisfied our primary and secondary outcome measures. One RCT demonstrated that HOAs are lower following EK and some lower quality evidence suggests that endothelial rejection episodes may be less with EK. These findings should be interpreted with caution as they are based on data with risk of biases. Further RCTs of visual and refractive outcomes needs to be performed in this field, comparing EK to PKP, with a larger sample size and at least five years of follow up. To avoid bias due to a surgeon's learning curve, procedures should be performed by experienced surgeons only. Quality of life and vision should also be evaluated. The risk of endothelial rejection will be difficult to address in the context of a RCT because of power considerations but large non-randomised comparative case series and corneal graft registry outcome data will be useful in this regard.
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Affiliation(s)
- Mayank A Nanavaty
- Queen Victoria Hospital NHS Foundation Trust, Holtye Road, East Grinstead, West Sussex, UK, RH19 3DZ
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