Selective Endothelialectomy in Peters Anomaly: A Novel Surgical Technique and Its Clinical Outcomes in Children

Long-Term Outcomes of Pediatric Keratoplasty at a Tertiary Care Center

PURPOSE

To report the indications, postoperative visual outcomes, and long-term graft survival of primary pediatric keratoplasties performed at a single tertiary care center.

METHODS

We conducted a retrospective review of pediatric patients (16 years and younger) who underwent surgical intervention for corneal opacity at a tertiary care center to evaluate long-term graft survival and visual rehabilitation.

RESULTS

Seventy-three eyes of 46 patients met inclusion criteria. The mean patient age at the time of transplantation was 7.44 years (range, 5 months-15.72 years), and the average follow-up time was 5.82 years. Forty eyes (56%) had graft failure occurring at a mean time of 16.33 months (range, 27 days-12.58 years), of which 25 eyes (62.5%) underwent repeat keratoplasty. Cumulative graft survival probabilities at 1, 3, 5, and 7 years after keratoplasty were 60%, 55%, 44%, and 44%, respectively. Cox proportional hazards regression analysis showed Black ethnicity [hazard ratio (HR) = 4.72; confidence interval (CI), 1.16-19.23], mixed/other ethnicity (HR = 6.67, CI, 1.58-28.16), and keratoplasty in combination with another procedure (HR = 2.88; CI, 1.35-6.15) as significant risk factors of graft failure. 47 eyes (64%) achieved ambulatory vision (20/800 or better) at the last follow-up. Age younger than 5 years at time of keratoplasty was associated with better visual outcomes in patients with congenital disease (P = 0.0017).

CONCLUSIONS

Pediatric keratoplasty has a high rate of graft failure but can achieve ambulatory vision in >60% of patients. Keratoplasty outcomes are improved in non-Hispanic, White patients and when the intervention is performed alone. Younger age at time of keratoplasty for congenital conditions improves the likelihood of overall visual rehabilitation.

Keratoplasty: are children missing out on the lamellar revolution-the 2023 Bowman Club, David L. Easty Lecture

There has been a growing interest in lamellar keratoplasty over penetrating keratoplasty in the treatment of cornea diseases. Children, in particular, may benefit from lamellar keratoplasty due to faster visual recovery, better outcomes, fewer eye drops and earlier amblyopia treatment. This review aims to examine the trends, surgical techniques and outcomes in paediatric lamellar keratoplasty. Additionally, alternative treatment modalities to keratoplasty such as selective endothelium removal in Peters anomaly and ophthalmic non-steroidal anti-inflammatory drugs eyedrops in congenital hereditary endothelial dystrophy are also discussed.

Encountering the clinical complexity of type II Peters anomaly management approaches: a case report

Anterior segment dysgenesis exerts its influence on a diverse array of ocular structures, encompassing the cornea, iris, ciliary body, anterior chamber and lens. We present a 20-month-old boy with bilateral corneal opacity. The visual acuity (VA) was 6/480 in both eyes. Upon examination, we found bilateral central corneal opacity with keratolenticular adhesions, anterior lens dislocation and opacification, aniridia. The clinical findings indicate diagnosis features of type II Peters anomaly (PA). Lens aspiration combined with adhesiolysis on the left eye (LE) was performed to address cataract-induced visual axis obstruction and prevent corneal decompensation from keratolenticular adhesions. We contemplated on prioritizing surgery for the LE initially due to the less severe corneal opacity compared to the right eye (RE). Further evaluations are required to determine the visual enhancement and the necessity of additional procedures. The management of type II PA proved to be a challenging experience. Cautious manipulation and extensive counseling can prevent further corneal decompensation.

The 2023 Doyne Lecture-a cornea care system: evolution

Blindness and visual impairment affect the quality of life of the individual and their family members. Corneal opacities are a key cause of vision loss around the world, especially in low-income and middle-income countries (LMIC). Corneal blindness and vision loss impacts every age group, and the risk factors and the causes are also varied. Socio-economic factors also play a significant role in its prevalence. Preventing, treating, and managing corneal conditions in LMIC contexts can therefore be quite complex and challenging. A model of eye care delivery developed and refined over the past four decades, the L V Prasad Eye Institute's cornea care system presents an example and a sense of hope. The model takes corneal care from world-class facilities in urban locations to rural locations, overcoming a variety of challenges. The initial breakthrough came with solving and ensuring a steady supply of corneal tissue. Then to training high-quality resources, building capacity, and investing in research that translates from the bench to the bedside. A variety of innovations, both in diagnosis and the operating theatre, have paved for improved outcomes that are tailored for the contexts in which this system operates. The institute envisions a future where its work further narrows the gap in eye care disparities and leads to life-changing impact in ophthalmic care of the cornea.

Emerging alternatives to keratoplasty for corneal endothelial cell dysfunction

PURPOSE OF REVIEW

While effective for treating endothelial dysfunction, keratoplasty has shortcomings including limited access to donor tissue for much of the world. Thus, alternative strategies are under development. This review explores the main advancements achieved in this field during 2022-2023.

RECENT FINDINGS

Recent publications further support the validity of intracameral cultivated allogeneic endothelial cell injection and Descemet stripping only, while emphasizing the benefits of adjunctive Rho-associated kinase inhibitor (ROCKi) therapy. New donor-independent artificial implants, such as EndoArt, show favorable results. Multiple pharmacologic agents, especially ROCKi, show promise as monotherapies, yet none are currently approved for human treatment. Multiple regenerative and genetic therapies are being investigated but all are still in preclinical stages.

SUMMARY

A plethora of innovative alternatives to keratoplasty for endothelial disease is in development. Among these, surgical methods are still the mainstay of treatment and closest to clinical application, though further studies to establish their benefits over keratoplasty are needed. Albeit promising, pharmacologic, regenerative, and genetic approaches require validation and are farther from clinical application.

Congenital anterior segment ocular disorders: Genotype-phenotype correlations and emerging novel mechanisms

Development of the anterior segment of the eye requires reciprocal sequential interactions between the arising tissues, facilitated by numerous genetic factors. Disruption of any of these processes results in congenital anomalies in the affected tissue(s) leading to anterior segment disorders (ASD) including aniridia, Axenfeld-Rieger anomaly, congenital corneal opacities (Peters anomaly, cornea plana, congenital primary aphakia), and primary congenital glaucoma. Current understanding of the genetic factors involved in ASD remains incomplete, with approximately 50% overall receiving a genetic diagnosis. While some genes are strongly associated with a specific clinical diagnosis, the majority of known factors are linked with highly variable phenotypic presentations, with pathogenic variants in FOXC1, CYP1B1, and PITX2 associated with the broadest spectrum of ASD conditions. This review discusses typical clinical presentations including associated systemic features of various forms of ASD; the latest functional data and genotype-phenotype correlations related to 25 ASD factors including newly identified genes; promising novel candidates; and current and emerging treatments for these complex conditions. Recent developments of interest in the genetics of ASD include identification of phenotypic expansions for several factors, discovery of multiple modes of inheritance for some genes, and novel mechanisms including a growing number of non-coding variants and alleles affecting specific domains/residues and requiring further studies.

Peters anomaly: An overview

Peters anomaly (PA) is a rare, often bilateral, congenital corneal opacity, usually with a sporadic inheritance pattern, characterized by corneal opacities and irido-corneal or lenticular-corneal adhesions with a defect in the Descemet's membrane, occurring due to anterior segment dysgenesis during fetal development. Due to other ocular and systemic comorbidities, a team comprising pediatric cornea, glaucoma, and strabismus specialists in addition to a pediatrician and geneticist is necessary for the appropriate management of these children. Since the outcome of pediatric penetrating keratoplasty is variable and has a higher chance of failure when accompanied by additional procedures, such as lensectomy and vitrectomy, minimally invasive alternatives are increasingly being offered to these patients. Of note is the recently reported novel procedure: selective endothelialectomy for PA, which avoids the need for a corneal transplant and results in gradual clearing of the corneal opacity over time. In this overview, we aimed to describe the etiology, classification, pathophysiology, histopathology, clinical features, and management of PA.