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Alió JL, Niazi S, Doroodgar F, Barrio JLAD, Hashemi H, Javadi MA. Main issues in penetrating keratoplasty. Taiwan J Ophthalmol 2024; 14:50-58. [PMID: 38654981 PMCID: PMC11034681 DOI: 10.4103/tjo.tjo-d-24-00001] [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: 12/31/2023] [Accepted: 01/09/2024] [Indexed: 04/26/2024] Open
Abstract
This review explores contemporary challenges in penetrating keratoplasty (PK), focusing on technical intricacies, technological advancements, and strategies for preventing graft rejection. A systematic literature search from January 2018 to July 2023 was conducted across PubMed, Cochrane, Web of Science, Scopus, and EMBASE. The inclusion criteria comprised studies on PK and its comparison with other corneal pathologies, with emphasis on keratoconus (KC). Two independent reviewers screened studies, extracting relevant data. The review covers PK evolution, highlighting infra-red femtosecond lasers' impact on graft shapes, minimizing astigmatism, and enhancing wound healing. Graft rejection, a primary complication, is examined, detailing risk factors and preventive measures. Preoperative considerations, diagnostic techniques for rejection, and PK in KC are discussed. Postoperative care's significance, including intraocular pressure monitoring and steroid administration, is emphasized. The paper concludes with a comprehensive approach to prevent graft rejection, involving topical and systemic medications. An outlook on evolving monoclonal antibody research is presented. As the field progresses, personalized approaches and ongoing therapeutic exploration are expected to refine strategies, enhancing PK outcomes.
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Affiliation(s)
- Jorge L. Alió
- Division of Ophthalmology, Universidad Miguel Hernández, Alicante, Spain
- Vissum Miranza Alicante, Alicante, Spain
| | - Sana Niazi
- Translational Ophthalmology Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Negah Aref Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Farideh Doroodgar
- Translational Ophthalmology Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Negah Aref Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Hassan Hashemi
- Noor Research Center for Ophthalmic Epidemiology, Noor Eye Hospital, Tehran, Iran
| | - Mohammad Ali Javadi
- Ophthalmic Research Center, Labbafinezhad Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Eleiwa T, Elsawy A, Ozcan E, Chase C, Feuer W, Yoo SH, Perez VL, Abou Shousha MF. Prediction of corneal graft rejection using central endothelium/Descemet's membrane complex thickness in high-risk corneal transplants. Sci Rep 2021; 11:14542. [PMID: 34267265 PMCID: PMC8282599 DOI: 10.1038/s41598-021-93892-4] [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: 04/22/2021] [Accepted: 06/08/2021] [Indexed: 11/09/2022] Open
Abstract
To determine whether measurements of Endothelium/Descemet complex thickness (En/DMT) are of predictive value for corneal graft rejection after high-risk corneal transplantation, we conducted this prospective, single-center, observational case series including sixty eyes (60 patients) at high risk for corneal graft rejection (GR) because of previous immunologic graft failure or having at least two quadrants of stromal vascularization. Patients underwent corneal transplant. At 1st, 3rd, 6th, 9th, and 12th postoperative month, HD-OCT imaging of the cornea was performed, and the corneal status was determined clinically at each visit by a masked cornea specialist. Custom-built segmentation tomography algorithm was used to measure the central En/DMT. Relationships between baseline factors and En/DMT were explored. Time dependent covariate Cox survival regression was used to assess the effect of post-operative En/DMT changes during follow up. A longitudinal repeated measures model was used to assess the relationship between En/DMT and graft status. Outcome measures included graft rejection, central Endothelium/Descemet's complex thickness, and central corneal thickness (CCT). In patients with GR (35%), the central En/DMT increased significantly 5.3 months (95% CI: 2, 11) prior to the clinical diagnosis of GR, while it remained stable in patients without GR. During the 1-year follow up, the rejected grafts have higher mean pre-rejection En/DMTs (p = 0.01), compared to CCTs (p = 0.7). For En/DMT ≥ 18 µm cut-off (at any pre-rejection visit), the Cox proportional hazard ratio was 6.89 (95% CI: 2.03, 23.4; p = 0.002), and it increased to 9.91 (95% CI: 3.32, 29.6; p < 0.001) with a ≥ 19 µm cut-off. In high-risk corneal transplants, the increase in En/DMT allowed predicting rejection prior to the clinical diagnosis.
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Affiliation(s)
- Taher Eleiwa
- Bascom Palmer Eye Institute, Miller School of Medicine, University of Miami, 900 NW 17 Street, Miami, FL, 33136, USA.,Department of Ophthalmology, Faculty of Medicine, Benha University, Benha, Egypt
| | - Amr Elsawy
- Bascom Palmer Eye Institute, Miller School of Medicine, University of Miami, 900 NW 17 Street, Miami, FL, 33136, USA.,Electrical and Computer Engineering, University of Miami, Miami, FL, USA
| | - Eyup Ozcan
- Bascom Palmer Eye Institute, Miller School of Medicine, University of Miami, 900 NW 17 Street, Miami, FL, 33136, USA
| | - Collin Chase
- Bascom Palmer Eye Institute, Miller School of Medicine, University of Miami, 900 NW 17 Street, Miami, FL, 33136, USA.,Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - William Feuer
- Bascom Palmer Eye Institute, Miller School of Medicine, University of Miami, 900 NW 17 Street, Miami, FL, 33136, USA
| | - Sonia H Yoo
- Bascom Palmer Eye Institute, Miller School of Medicine, University of Miami, 900 NW 17 Street, Miami, FL, 33136, USA
| | - Victor L Perez
- Duke Eye Center, Duke University School of Medicine, Durham, NC, USA
| | - Mohamed F Abou Shousha
- Bascom Palmer Eye Institute, Miller School of Medicine, University of Miami, 900 NW 17 Street, Miami, FL, 33136, USA. .,Electrical and Computer Engineering, University of Miami, Miami, FL, USA. .,Biomedical Engineering, University of Miami, Miami, FL, USA.
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3
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The Use of Digital Microscopy to Compare the Thicknesses of Normal Corneas and Ex Vivo Rejected Corneal Grafts with a Focus on the Descemet's Membrane. J Ophthalmol 2019; 2019:8283175. [PMID: 31827912 PMCID: PMC6885265 DOI: 10.1155/2019/8283175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 10/05/2019] [Indexed: 01/15/2023] Open
Abstract
Objective To compare the thickness of corneal layers, specifically the Descemet's membrane (DM), in normal corneas and in failed grafts due to rejection (FGRs) using the digital histopathology and to propose a model for the measurement of corneal layers using this method. Methods This is a prospective, cross-sectional study performed at the MUHC-McGill University Ocular Pathology & Translational Research Laboratory (McGill University, Montreal, Canada). Histopathological sections of 25 normal human corneas and 40 FGRs were fully digitalized and examined. Inclusion criteria: samples diagnosed as normal corneas or FGRs, from patients older than 18 years of age. Exclusion criteria: histopathological sections without adequate tissue or missing epidemiological information. For each sample, the thicknesses of the epithelium, stroma, and DM were acquired. From a perpendicular plane of reference, two central measurements and two nasal and two temporal peripheral measurements were obtained. Results There were differences between the normal and FGR groups in the mean central thickness of the epithelium (p < 0.001), the nasal and temporal stromal regions (p < 0.001), and of the DM in the nasal and temporal regions (p < 0.001). Compared with the extremities of the sample (nasal and temporal), the mean thickness of the DM in normal corneas was lower in the central region (p < 0.001), and this difference was not found in the FGR group. Conclusions Normal corneas have a thinner epithelium in the central region than the FGR group. In addition, the stroma and DM thicknesses of the nasal and temporal periphery were significantly higher in normal corneas than in those from the FGR group. The digital microscopy protocol applied in this study may be useful for further research studies regarding cornea and other tissues.
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Elsawy A, Abdel-Mottaleb M, Sayed IO, Wen D, Roongpoovapatr V, Eleiwa T, Sayed AM, Raheem M, Gameiro G, Shousha MA. Automatic Segmentation of Corneal Microlayers on Optical Coherence Tomography Images. Transl Vis Sci Technol 2019; 8:39. [PMID: 31211004 PMCID: PMC6561132 DOI: 10.1167/tvst.8.3.39] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 03/25/2019] [Indexed: 11/28/2022] Open
Abstract
Purpose To propose automatic segmentation algorithm (AUS) for corneal microlayers on optical coherence tomography (OCT) images. Methods Eighty-two corneal OCT scans were obtained from 45 patients with normal and abnormal corneas. Three testing data sets totaling 75 OCT images were randomly selected. Initially, corneal epithelium and endothelium microlayers are estimated using a corneal mask and locally refined to obtain final segmentation. Flat-epithelium and flat-endothelium images are obtained and vertically projected to locate inner corneal microlayers. Inner microlayers are estimated by translating epithelium and endothelium microlayers to detected locations then refined to obtain final segmentation. Images were segmented by trained manual operators (TMOs) and by the algorithm to assess repeatability (i.e., intraoperator error), reproducibility (i.e., interoperator and segmentation errors), and running time. A random masked subjective test was conducted by corneal specialists to subjectively grade the segmentation algorithm. Results Compared with the TMOs, the AUS had significantly less mean intraoperator error (0.53 ± 1.80 vs. 2.32 ± 2.39 pixels; P < 0.0001), it had significantly different mean segmentation error (3.44 ± 3.46 vs. 2.93 ± 3.02 pixels; P < 0.0001), and it had significantly less running time per image (0.19 ± 0.07 vs. 193.95 ± 194.53 seconds; P < 0.0001). The AUS had insignificant subjective grading for microlayer-segmentation grading (4.94 ± 0.32 vs. 4.96 ± 0.24; P = 0.5081), but it had significant subjective grading for regional-segmentation grading (4.96 ± 0.26 vs. 4.79 ± 0.60; P = 0.025). Conclusions The AUS can reproduce the manual segmentation of corneal microlayers with comparable accuracy in almost real-time and with significantly better repeatability. Translational Relevance The AUS can be useful in clinical settings and can aid the diagnosis of corneal diseases by measuring thickness of segmented corneal microlayers.
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Affiliation(s)
- Amr Elsawy
- Bascom Palmer Eye Institute, Miller School of Medicine, University of Miami, Miami, FL, USA.,Electrical and Computer Engineering, University of Miami, Coral Gables, FL, USA
| | | | - Ibrahim-Osama Sayed
- Bascom Palmer Eye Institute, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Dan Wen
- Bascom Palmer Eye Institute, Miller School of Medicine, University of Miami, Miami, FL, USA
| | | | - Taher Eleiwa
- Bascom Palmer Eye Institute, Miller School of Medicine, University of Miami, Miami, FL, USA.,Ophthalmology Department, Benha Faculty of Medicine, Egypt
| | - Ahmed M Sayed
- Bascom Palmer Eye Institute, Miller School of Medicine, University of Miami, Miami, FL, USA.,Biomedical Engineering Department, Faculty of Engineering, Helwan University, Egypt
| | - Mariam Raheem
- Bascom Palmer Eye Institute, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Gustavo Gameiro
- Bascom Palmer Eye Institute, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Mohamed Abou Shousha
- Bascom Palmer Eye Institute, Miller School of Medicine, University of Miami, Miami, FL, USA.,Electrical and Computer Engineering, University of Miami, Coral Gables, FL, USA.,Biomedical Engineering, University of Miami, Coral Gables, FL, USA
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Smith C, Kaitis D, Winegar J, Edelstein S, Council M, Kontadakis G, Bentivegna R, Shousha MA. Comparison of endothelial/Descemet's membrane complex thickness with endothelial cell density for the diagnosis of corneal transplant rejection. Ther Adv Ophthalmol 2018; 10:2515841418814187. [PMID: 30560229 PMCID: PMC6293363 DOI: 10.1177/2515841418814187] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 10/19/2018] [Indexed: 11/19/2022] Open
Abstract
Purpose: This study compared the effectiveness of endothelial/Descemet’s membrane
complex thickness obtained using high-definition anterior segment optical
coherence tomography with endothelial cell density obtained using confocal
microscopy as diagnostic tools in predicting corneal transplant
rejection. Methods: This observational, prospective, cross-sectional study evaluated penetrating
keratoplasty grafts. Slit lamp examination organized the grafts into healthy
or rejecting grafts. Grafts were scanned using both high-definition anterior
segment optical coherence tomography and confocal microscopy. Central
corneal thickness, endothelial/Descemet’s membrane complex thickness,
endothelial cell density, and coefficient of variation were each compared
with the clinical status. Descemet’s rejection index, defined by
endothelial/Descemet’s membrane complex thickness divided by central corneal
thickness multiplied by 33, further compared endothelial/Descemet’s membrane
complex thickness with central corneal thickness. Results: Endothelial/Descemet’s membrane complex thickness, central corneal thickness,
and Descemet’s rejection index were all able to differentiate between clear
and rejected corneal grafts (p < 0.0001,
p = 0.001, and p = 0.012,
respectively). Endothelial cell density and coefficient of variation did not
correlate with the clinical status (p = 0.054 and
p = 0.102, respectively). Endothelial/Descemet’s
membrane complex thickness had the largest area under the curve using
receiver operating characteristic curves (p < 0.0001).
Endothelial/Descemet’s membrane complex thickness had a sensitivity of 86%
and specificity of 81% with a cutoff value of >16.0 µm
(p < 0.0001). The sensitivity and specificity of
endothelial cell density were both 71% with a cutoff value of ⩽897
cells/mm2 (p = 0.053). There was a high
correlation between endothelial/Descemet’s membrane complex thickness and
both Descemet’s rejection index and central corneal thickness
(p < 0.0001). Conclusion: Endothelial/Descemet’s membrane complex thickness measured by high-definition
anterior segment optical coherence tomography is a useful parameter for the
diagnosis of corneal graft rejection. The diagnostic performance of
endothelial/Descemet’s membrane complex thickness was significantly better
than that of endothelial cell density and central corneal thickness.
Endothelial cell density and the coefficient of variation were unable to
diagnose corneal graft rejection in our cross-sectional study.
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Affiliation(s)
| | - Daniel Kaitis
- Saint Louis University Eye Institute, St. Louis, MO, USA
| | - Jordan Winegar
- Saint Louis University Eye Institute, St. Louis, MO, USA
| | - Sean Edelstein
- Saint Louis University Eye Institute, St. Louis, MO, USA
| | | | | | | | - Mohamed Abou Shousha
- Department of Ophthalmology, Bascom Palmer Eye Institute, 900 NW 17th Street, Miami, FL 33136, USA
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