Clinical features and management of keratoconjunctivitis associated with inadequate tear drainage

OBJECTIVE

To describe clinical features and management of toxic keratoconjunctivitis associated with punctal and (or) canaliculus stenosis (toxic soup syndrome).

DESIGN

Retrospective observational case series.

METHODS

Electronic medical record database search for the keywords "toxic soup syndrome" and retrospective chart review were performed. Thirty-five eyes of 25 patients were seen at a tertiary cornea clinic between January 2017 and December 2021. Sex, age, distance-corrected visual acuity, topical medications, symptoms, clinical signs, and outcomes after medical and surgical interventions were analyzed. The main outcome measured was improvement in ocular surface signs and symptoms after interventions.

RESULTS

Overall, 35 eyes of 25 patients with a mean age of 66.8 ± 12.8 years, of which 72% were female, were included. The primary complaint was hyperemia and epiphora in all patients. Rosacea or meibomian gland disease were present in all patients, 7 (28%) had glaucoma, and 7 (28%) developed limbal stem cell deficiency. Twenty-two patients (88%) were using topical medications on presentation. All eyes had either punctal plugs, cauterized puncta, or punctal and (or) canaliculus stenosis. Management of all patients consisted of suspension of all preserved topical medications and institution of some type of anti-inflammatory therapy. Nineteen patients (76%) improved after improvement of lacrimal drainage. One patient with severe resistance in the canaliculus required ongoing preservative-free topical steroids.

CONCLUSIONS

Chronic drug-induced or pooled inflammatory mediators causing toxic conjunctivitis may be aggravated by punctal and (or) canaliculus stenosis, leading to toxic soup syndrome. Clearance of punctal obstruction leads to improvement in most patients.

The Efficacy and Safety of Standard versus Soft Topical Steroids after Cataract Surgery: A Systematic Review and Meta-analysis

TOPIC

Review of the efficacy and safety of standard versus soft topical steroid application after cataract surgery.

CLINICAL RELEVANCE

The control of postoperative inflammation is the mainstay of treatment after cataract surgery. However, no consensus exists regarding the postoperative steroid of choice. Basing the choice of topical postoperative steroidal treatment on high-quality data regarding both risks and benefits of various drugs would be advantageous for both patients and clinicians.

METHODS

A systematic search of the PubMed, Scopus, and Embase electronic databases for all peer-reviewed published randomized control trials that included clinical outcomes of topical steroidal treatment after uneventful cataract surgery was performed. Individual study data were extracted and evaluated in a weighted pooled analysis including grading of total anterior chamber (AC) inflammation, AC cells, AC flare, postoperative visual acuity (VA), intraocular pressure (IOP), and rate of adverse events (AEs).

RESULTS

Overall, 508 studies were found, of which 7 were eligible for the systematic review and ultimately were included for analysis, reporting on 593 patients from 5 countries. Age of included patients, when available, ranged between 3.7 and 73.4 years. Follow-up data were available for analysis at 1, 7, and 28 days after surgery. Except for a significantly lower grade of AC flare in the standard steroid group at day 7 (standardized mean difference, 0.26; 95% confidence interval, 0.05-0.47; I2 = 0%), inflammatory activity measurements displayed insignificant differences at every other follow-up (days 1 and 28 after surgery). Pooled analysis of IOP at each follow-up demonstrated a higher IOP at the 7-day visit in the standard steroid group, whereas IOP at other time points was comparable among the groups. Qualitative analysis of ocular AEs showed similarities among the groups.

DISCUSSION

The findings of this study suggest that for the average patient, both groups produce a comparable effect on both AC inflammation and postoperative IOP and VA.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Comparison of long-term outcomes of simultaneous accelerated corneal crosslinking combined with intracorneal ring segment or topography-guided PRK

PURPOSE

To compare long-term outcomes of simultaneous accelerated corneal crosslinking (CXL) with intrastromal corneal ring segments (CXL-ICRS) with simultaneous accelerated CXL with topography-guided photorefractive keratectomy (CXL-TG-PRK) in progressive keratoconus (KC).

SETTING

Kensington Eye Institute and Bochner Eye Institute, Toronto, Canada.

DESIGN

Prospective nonrandomized interventional study.

METHODS

The change in visual and topographical outcomes of CXL-ICRS and CXL-TG-PRK 4 to 5 years postoperatively were compared using linear regression models adjusted for preoperative corrected distance visual acuity (CDVA) and maximum keratometry (Kmax).

RESULTS

57 eyes of 43 patients with progressive KC who underwent simultaneous accelerated (9 mW/cm 2 , 10 minutes) CXL-ICRS (n = 32) and CXL-TG-PRK (n = 25) were included. Mean follow-up duration was 51.28 (9.58) and 54.57 (5.81) months for the CXL-ICRS and CXL-TG-PRK groups, respectively. Initial mean Kmax was higher in the CXL-ICRS group compared with the CXL-TG-PRK group (60.68 ± 6.81 diopters [D] vs 57.15 ± 4.19 D, P = .02). At the last follow-up, change (improvement) in logMAR uncorrected distance visual acuity (UDVA) compared with that preoperatively was significant with CXL-ICRS (-0.31 ± 0.27, P < .001, which is equivalent to approximately 3 lines) and not significant with CXL-TG-PRK (-0.06 ± 0.42, P = .43). The logMAR CDVA improved significantly with CXL-ICRS (-0.22 ± 0.20, P < .001), but not with CXL-TG-PRK (-0.05 ± 0.22, P = .25). Adjusting for baseline Kmax and CDVA, the improvement in UDVA was significantly greater with CXL-ICRS than with CXL-TG-PRK (-0.27, 95% CI, 0.06-0.47, P = .01). Improvement in CDVA was not significantly different.

CONCLUSIONS

In this cohort of progressive KC with long-term follow-up, UDVA showed more improvement with accelerated CXL-ICRS than with CXL-TG-PRK.

Validation of preloaded DMEK donor tissues: a laboratory-based study on endothelial cell viability and comparison of two F-mark inks

OBJECTIVE

To investigate endothelial cell loss (ECL) associated with Descemet membrane endothelial keratoplasty (DMEK) donor tissues preloaded in the DMEK RAPID transport system after 1 and 5 days and to compare prestamping with 2 different F-mark inks.

METHODS

DMEK donor tissues were stripped, marked with gentian violet dye applied as an F-mark, trephined, stained with trypan blue, and then preloaded into the DMEK RAPID transport system by an eye bank technician. Preloaded DMEK tissues were then unfolded and stained with calcein AM after 1 or 5 days of storage. Tissues were imaged, analyzed for total tissue ECL, and immunostained for corneal endothelium markers zonular occludens-1 and xCD166. Additionally, ECL and the intensity of an F-mark caused by 2 different inks were quantified.

RESULTS

Preloaded DMEK tissues displayed an average ECL of 11.9% ± 4.5% (n = 8) at 1 day and 9.9% ± 4.2% (n = 9) at 5 days. No difference was found between the 2 groups. Zonular occludens-1 and activated leukocyte cell adhesion molecule (ALCAM; also know as CD166) staining showed that the corneal endothelial monolayer remained intact on preloaded tissues. On 5-day preloaded DMEK tissues, the average ECL and mean grayscale caused by the Keir Surgical ink F-mark and the Cardinal Health ink F-mark were 4.3% ± 0.8% and 158.5 ± 13.9% and 5.0% ± 1.1% and 142.9% ± 20.0%, respectively. No difference was found between the F-mark inks.

CONCLUSION

Preloaded DMEK donor tissues resulted in an acceptable ECL range after 1 and 5 days of storage and were deemed suitable for transplantation. Both F-mark inks are acceptable for prestamping preloaded DMEK tissues prior to surgical transplantation with comparable ECL and intensities.

KAMRA presbyopic inlay refractive outcomes: a Canadian perspective

OBJECTIVE

To retrospectively analyze the visual outcomes of KAMRA (AcuFocus Inc, Irvine, Calif.) inlay insertion in a cohort of patients reporting success of procedure, complications, patient satisfaction, and refractive outcomes.

DESIGN

Retrospective trial at the TLC Laser Centre, Toronto.

METHODS

A total of 5 surgeons at the practice inserted 35 KAMRA inlays in 35 patients between October 2012 and June 2014. Some patients had a sole KAMRA inlay insertion, whereas others had combined laser vision correction (LVC) and KAMRA inlay on either the same day or sequentially. There was a small cohort of patients who had previous unrelated LVC. Mean time of follow-up was 299 days.

RESULTS

After KAMRA inlay insertion there was a significant improvement in uncorrected near visual acuity (p = 0.00009), uncorrected intermediate visual acuity (p = 0.00006), and uncorrected distance visual acuity (p = 0.02), but levels of patient dissatisfaction were 43%. The most common cause for dissatisfaction was requirements for readers (23%), followed by dysphotopsias (11%). The explantation rate was 11.42%, and 28.5% of patients required enhancements after inlay insertion.

CONCLUSIONS

The KAMRA corneal inlay has significant improvements in uncorrected near visual acuity, uncorrected intermediate visual acuity, and uncorrected distance visual acuity when used in isolation or combined with LVC. Appropriate patient selection is crucial. This procedure should not be used as first-line presbyopia management because of low levels of patient satisfaction, biocompatibility concerns, and explantation rates.

Systemic antibiotic treatment for meibomian gland dysfunction-A systematic review and meta-analysis

PURPOSE

To review the efficacy and safety of oral doxycycline antibiotics versus macrolides in the treatment of meibomian gland dysfunction (MGD).

DESIGN

Systematic review and meta-analysis.

METHODS

We performed a systematic search of electronic databases for all peer-reviewed published studies which included clinical outcomes of oral antibiotic MGD treatment. Individual study data were extracted and evaluated in a weighted pooled analysis, including total sign and symptom scores, meibomian gland secretion score, tear break-up time (TBUT), fluorescein staining score and rate of complications.

RESULTS

Two thousand nine hundred and thirty-three studies were found, of which 54 were eligible for the systematic review, and six prospective studies were ultimately included for analysis, reporting on 563 cases from three countries. Age of affected patients ranged between 12 and 90 years. Overall, both treatment methods induced improvement in MGD signs and symptoms. In pooled analysis, macrolides were significantly superior in the total signs score (pooled standardized mean difference (SMD) -0.51, 95% confidence interval (CI): -0.99 to -0.03), meibomian gland secretion score (pooled SMD -0.25, 95%CI: [-0.48, -0.03]), TBUT (SMD -0.31, 95%CI: [-0.50, -0.13]) and fluorescein staining score (SMD -1.01, 95%CI: [-1.72, -0.29]). Moreover, while no severe complications were reported for both treatments, the macrolide group exhibited significantly less adverse events (pooled odds ratio 0.24 with a 95% CI of 0.16 to 0.34).

CONCLUSIONS

Both macrolides and tetracyclines are effective treatments for MGD. In this study, macrolides exhibited better efficacy and safety profile compared to tetracyclines.

Clinical Outcomes of Transscleral-Sutured Intraocular Lens Combined With Descemet Membrane Endothelial Keratoplasty

PURPOSE

The aim of the study was to report clinical outcomes of Descemet membrane endothelial keratoplasty (DMEK) combined with transscleral-sutured intraocular lens (IOL) compared with DMEK combined with phacoemulsification and posterior chamber IOL (Phaco-DMEK).

METHODS

A retrospective chart review of all patients who underwent DMEK combined with transscleral-sutured intraocular lens fixation or combined with phacoemulsification for Fuchs endothelial corneal dystrophy from 2016 to 2021 at the Toronto Western Hospital or the Kensington Eye Institute (Toronto, ON, Canada) and had at least 18 months of follow-up was performed. Main outcomes were postoperative distance-corrected visual acuity, rebubbling rate, graft survival rate, and complications.

RESULTS

Twenty-one cases of DMEK combined with transscleral-sutured IOL (DMEK-TSS-IOL) and 44 cases of Phaco-DMEK were evaluated. Twelve eyes (57.15%) had a foldable acrylic 3-piece IOL (AR40E) and 9 (42.85%) had a single-piece polymethylmethacrylate (PMMA) IOL (CZ70BD). LogMAR distance-corrected visual acuity improved significantly from 1.48 ± 0.62 (SD) to 0.86 ± 0.82 ( P = 0.01) 12 months after DMEK-TSS-IOL and from 0.41 ± 0.29 logMAR to 0.11 ± 0.11 logMAR ( P < 0.0001) after Phaco-DMEK. No statistically significant differences were observed in donor ( P = 0.97) or 1-year postoperative endothelial cell density ( P = 0.11) between the groups. Rebubbling was necessary in 33.33% of eyes in DMEK-TSS-IOL compared with 25% of Phaco-DMEK eyes ( P = 0.55). Graft survival rate was 76.19% in the DMEK-TSS-IOL group compared with 90.90% in the Phaco-DMEK group ( P = 0.13).

CONCLUSIONS

Transscleral-sutured IOL combined with DMEK is an option for the management of endothelial diseases in aphakic eyes or those which require IOL exchange for the experienced surgeon. However, when compared with routine Phaco-DMEK, there are higher complication and lower survival rates at 18 months.

A randomized controlled trial comparing femtosecond-enabled deep anterior lamellar keratoplasty and standard deep anterior lamellar keratoplasty (FEDS Study)

OBJECTIVES

To compare outcomes of femtosecond-enabled deep anterior lamellar keratoplasty (FE-DALK) and standard deep anterior lamellar keratoplasty (S-DALK).

METHODS

An open label, randomized controlled trial (Kensington Eye Institute, Toronto, ON, Canada) including 100 eyes of 97 participants with either keratoconus or corneal scarring, randomized to either FE-DALK (n = 48) or S-DALK (n = 49).

PRIMARY OUTCOMES

postoperative astigmatism and surgically induced corneal astigmatism (SIA) - both at 15 months.

SECONDARY OUTCOMES

6-, 12- and 15-month postoperative uncorrected- and best spectacle-corrected visual acuity, steep and flat keratometry, manifest sphere and astigmatism, rate of conversion to penetrating keratoplasty (PK), big-bubble success, central corneal thickness, endothelial cell count and complications.

RESULTS

In intention-to-treat analysis, mean postoperative astigmatism in the FE-DALK (n = 30) and S-DALK (n = 30) groups at 15 months was 7.8 ± 4.4 D and 6.3 ± 5.0 D, respectively (p = 0.282) with an adjusted mean difference of 1.3 D (95% CI -1.08, +3.65). Mean SIA (arithmetic) was 9.2 ± 7.8 and 8.8 ± 5.4 D, respectively (p = 0.838) with a mean difference of 0.4 D (95% CI -3.13, +3.85). In an analysis of successful DALK cases only, mean postoperative astigmatism in the FE-DALK (n = 24) and S-DALK (n = 20) groups at 15 months (after excluding 4 eyes with AEs) was 7.3 ± 4.4 and 6.2 ± 4.9 D, respectively (p = 0.531) with an adjusted mean difference of 0.9 D (95% CI -1.94, +3.71). Mean SIA (arithmetic) was 9.1 ± 7.8 and 7.9 ± 4.6 D, respectively (p = 0.547) with a mean difference of 1.2 D (95% CI -2.70,+5.02). Comparison of secondary outcomes showed only weak statistical evidence.

CONCLUSIONS

In this randomized controlled trial, FE-DALK and S-DALK showed comparable functional and anatomical outcomes.

Monkeypox-Associated Disciform Keratitis

PURPOSE

The purpose of this study was to describe a case of monkeypox (MPX)-associated disciform keratitis.

METHODS

This is a case report.

RESULTS

A 36-year-old male patient presented to the infectious diseases clinic with a 1-week history of disseminated pustular skin lesions, a 4-day history of constitutional symptoms, and redness in the left eye. Testing of blood, 2 skin lesions, and a conjunctival swab confirmed the presence of MPX virus by polymerase chain reaction. On ophthalmologic examination on the 17th day of illness, there was a corneal epithelial ridge that stained with fluorescein with disciform corneal edema and underlying keratic precipitates. The patient was treated with oral tecovirimat 600 mg twice a day for 14 days and topical prednisolone acetate 1% 4 times daily, starting 2 days later. On completion of oral treatment, his corneal findings had resolved except for a small subepithelial scar at which time topical steroids were tapered.

CONCLUSIONS

MPX may cause disciform keratitis and scarring that closely resembles other ocular viral infections. Clinical trials are urgently needed to define the optimal management of human MPX infections and reduce vision loss.

Economic appraisal of prosthetic replacement of ocular surface ecosystem in Canada

OBJECTIVE

To perform an economic appraisal of the Prosthetic Replacement of Ocular Surface Ecosystem (PROSE; BostonSight, Needham Heights, Mass.) lens in patients with a distorted corneal surface or ocular surface disease in Canada.

DESIGN

Retrospective observational cohort study with cost, cost-utility, and benefit-cost analyses.

PARTICIPANTS

Patients who received PROSE from the only PROSE clinic in Canada from 2018 to 2020.

METHODS

Visual acuity (VA) outcomes of the participants were assessed. Benefits were defined as VA improvements that were converted into utilities and then quality-adjusted life years. Economic values were derived via government statements, clinic financial statements, and published literature.

RESULTS

Average best-corrected VA (BCVA) improvement was -0.42 ± 0.41 logMAR (p = 2.68 × 10^-13) or Snellen 20/53 for the overall cohort, -0.51 ± 0.48 (p = 5.42 × 10^-8) or Snellen 20/65 for distorted corneal surface patients, and -0.31 ± 0.30 (p = 1.30 × 10^-7) or Snellen 20/41 for ocular surface disease patients. This corresponded to discounted quality-adjusted life year gains of 0.51, 0.65, and 0.42, respectively, over an estimated 5-year PROSE device lifespan. Average cost to fit a patient with PROSE was USD$5 469.85 (CAD$7 087.28), of which USD$4 971.38 (CAD$6 441.42) was clinic cost and USD$498.47 (CAD$645.87) was patient cost. Cost-utility was USD$10 256.47 (CAD$13 289.31) for the overall cohort, USD$8 439.79 (CAD$10 935.44) for distorted corneal surface patients, and US$13 069.90 (CAD$16 934.67) for ocular surface disease patients. The benefit-cost ratio was 34.4 for all, 43.8 for distorted corneal surface patients, and 28.3 for ocular surface disease patients.

CONCLUSIONS

Our economic appraisal demonstrated that PROSE treatment provides a significant, cost-effective benefit to Canadian patients with distorted corneal surfaces and ocular surface diseases. This indicates that PROSE clinics are an efficient investment.

Cost-Effectiveness of Preoperative Topical Antibiotic Prophylaxis for Endophthalmitis Following Cataract Surgery

PURPOSE

To determine the cost-effectiveness of preoperative topical antibiotic prophylaxis for the prevention of endophthalmitis following cataract surgery.

DESIGN

Cost-effectiveness analysis using a decision-analytic microsimulation model.

METHODS

Preoperative topical antibiotic prophylaxis vs no-prophylaxis costs and effects were projected over a life-time horizon for a simulated cohort of 500 000 adult patients (≥18 years old) requiring cataract surgery in theoretical surgical centers in the United States. Efficacy and cost (2021 US dollars) values were obtained from the literature and discounted at 3% per year.

RESULTS

Based on inputted parameters, the mean incidence of endophthalmitis following cataract surgery for preoperative topical antibiotic prophylaxis vs no-prophylaxis was 0.034% (95% CI 0%-0.2%) and 0.042% (95% CI 0%-0.3%), respectively-an absolute risk reduction of 0.008%. The mean life-time costs for cataract surgery with prophylaxis and no-prophylaxis were $2486.67 (95% CI $2193.61-$2802.44) and $2409.03 (95% CI $2129.94-$2706.69), respectively. The quality-adjusted life-years (QALYs) associated with prophylaxis and no-prophylaxis were 10.33495 (95% CI 7.81629-12.38158) and 10.33498 (95% CI 7.81284-12.38316), respectively. Assuming a cost-effectiveness criterion of ≤$50 000 per QALY gained, the threshold analyses indicated that prophylaxis would be cost-effective if the incidence of endophthalmitis after cataract surgery was greater than 5.5% or if the price of the preoperative topical antibiotic prophylaxis was less than $0.75.

CONCLUSIONS

General use of preoperative topical antibiotic prophylaxis is not cost-effective compared with no-prophylaxis for the prevention of endophthalmitis following cataract surgery. Preoperative topical antibiotic prophylaxis, however, would be cost-effective at a higher incidence of endophthalmitis and/or a substantially lower price for prophylaxis.

Five-Year Safety and Efficacy of Femtosecond Laser-Assisted Descemet Membrane Endothelial Keratoplasty

PURPOSE

The purpose of this study was to evaluate 5-year safety and efficacy outcomes of femtosecond-enabled Descemet membrane endothelial keratoplasty (F-DMEK) in patients with Fuchs' endothelial dystrophy (FED).

METHODS

This was a retrospective study, including patients with FED and cataract who underwent either F-DMEK (16 eyes of 15 patients) or manual DMEK (M-DMEK) (42 eyes of 37 patients) combined with cataract extraction. Outcome measures included visual acuity, graft detachment, graft survival, and endothelial cell loss.

RESULTS

The average follow-up in F-DMEK and M-DMEK was 57.1 ± 12.4 months and 58.5 ± 17.3 months, respectively ( P = 0.757). The rates of primary failure (0% vs. 9.5%, P = 0.567), secondary failure (0% for both), and graft rejection (0% vs. 7.1%, P = 0.533) did not differ significantly between the groups. Improvement in best spectacle-corrected visual acuity was similar in F-DMEK and M-DMEK (0.32 ± 0.27 logarithm of the minimum angle of resolution and 0.35 ± 0.44 logarithm of the minimum angle of resolution, respectively, P = 0.165) and persisted at 2, 3, 4, and 5 years and at the last follow-up. The rates of graft detachment and rebubbling were significantly lower with 6.25% in F-DMEK and 33.3% in M-DMEK ( P = 0.035). Cell-loss rates were lower in F-DMEK compared with M-DMEK throughout the follow-up, significantly so up to 2 years with a difference of 8.6% at 1 year ( P = 0.023), 11.8% at 2 years ( P = 0.021), 7.6% at 3 years ( P = 0.088), 5.8% at 4 years ( P = 0.256), 13.6% at 5 years ( P = 0.169), and 7.1% at the final follow-up ( P = 0.341).

CONCLUSIONS

F-DMEK had an excellent safety and efficacy profile which was maintained over 5 years of follow-up. Lower endothelial cell-loss rates in F-DMEK compared with M-DMEK may help extend the duration of graft survival.

Outcomes of keratolimbal allograft from ABO compatible donors for severe bilateral limbal stem cell deficiency

PURPOSE

To report outcomes of keratolimbal allograft (KLAL) compatible for both human leukocyte (HLA) and/or blood type using oral prednisone, mycophenolate, and tacrolimus, with basiliximab if panel reactive antibodies (PRA) are present. Intravenous immunoglobulin (IVIG) was used post-operatively if donor-specific anti-HLA antibodies (DSA) were present.

METHODS

Retrospective interventional series of consecutive patients with KLAL for limbal stem cell deficiency (LSCD) from HLA and/or blood type compatible deceased donors with a minimum follow-up time of 12 months. Main outcome measures were ocular surface stability, visual acuity and systemic immunosuppression (SI) adverse events.

RESULTS

Eight eyes of eight patients with mean age of 48.6 ± 10.1 years (range 34-65 years) were included. Mean follow-up time was 37.3 ± 22.7 months (range 12-71 months) following KLAL; four (50%) had combined LR-CLAL surgery. The etiologies of LSCD were Stevens-Johnson Syndrome (n = 4/8), aniridia (n = 2/8), chemical injury (n = 1/8) and atopic eye disease (n = 1/8). All patients had PRA present and received basiliximab infusions. 5/8 patients received IVIG based on DSA identified pre-operatively. At last follow-up, 7 eyes (87.5%) had a stable ocular surface; 1 eye (12.5%) developed failure and had keratoprosthesis implantation. There was a significant improvement in visual acuity from 1.65 ± 0.48 to 0.68 ± 0.34 logMAR (p = 0.01). SI was tolerated well with minimal adverse events.

CONCLUSIONS

Preliminary outcomes of KLAL with ABO compatible tissue using the Cincinnati protocol, preoperative basiliximab (when PRA present) and post-operative IVIG (when DSA present) are encouraging. This protocol may allow for utilization of deceased donor tissue with results approximating those of living donor tissue transplanted for severe bilateral LSCD.

Investigating the role of inflammation in keratoconus: A retrospective analysis of 551 eyes

PURPOSE

Keratoconus (KCN), classically defined as a noninflammatory corneal ectasia, was recently associated with chronic inflammation. This study aimed to further evaluate the association between inflammation and KCN severity by assessing patient tear films.

METHODS

Retrospective chart review of consecutive patients (July 2016-February 2020) referred to a tertiary KCN centre. Using tomography Kmax values, the worst-eyes of patients with a diagnosis of KCN and tear film test results were included. Eyes were stratified as matrix metalloproteinase-9 (MMP9) positive or negative and analyzed using independent t and Pearson chi-squared tests. A p-value ≤ 0.05 was considered significant.

RESULTS

551 (51.40%) unilateral eyes were included. Mean age was 30.1 years and 70.1% were male. 55.5% of the eyes were MMP9 positive. Mean corrected distance visual acuity was 20/30^<συπ>-3</sup> Snellen and Kmax was 60.1 Diopters. MMP9 positive eyes had a higher Kmax (p = 0.048), and were more likely from patients who were male (p < 0.001), had a paediatric history of asthma (p = 0.042), and used glasses (p = 0.041). MMP9 negative eyes more likely corresponded to soft contact lens users (p = 0.012). No other significant differences were found in risk factors, topography, tomography, and tear film osmolarity.

CONCLUSION

MMP9 positive keratoconic eyes had significantly higher Kmax readings which may correlate with increased disease severity, supporting an association between keratoconus and inflammation. Further research is warranted to evaluate the role of targeted therapy and contact lens use on MMP9 levels in keratoconic eyes and whether disease progression is affected.

Prosthetic Replacement of the Ocular Surface Ecosystem for Limbal Stem Cell Deficiency: A Case Series

OBJECTIVES

To assess outcomes of limbal stem cell deficiency (LSCD) in patients treated with Prosthetic Replacement of the Ocular Surface Ecosystem (PROSE).

METHODS

Retrospective case series. Patients with LSCD who received PROSE treatment were included. Data including best-corrected visual acuity (BCVA) and LSCD staging before and after PROSE dispensing were collected to characterize each case.

RESULTS

Five eyes of four patients were included. All patients were female, with an age range of 21 to 80 years. Each patient received a PROSE device with diameters ranging from 16 to 18.5 mm. Follow-up ranged from 11 to 29 months. Tolerated wear times ranged from 3.5 to 10 hr daily. Four eyes showed improved BCVA and unchanged LSCD staging as per the global consensus after PROSE treatment. Three of these eyes had stage 3 and one had stage 1C LSCD at diagnosis. The fifth eye had worse BCVA and recurrence of stage 3 LSCD post-living-related conjunctival limbal allograft transplant despite PROSE treatment.

CONCLUSIONS

Prosthetic Replacement of the Ocular Surface Ecosystem may be a viable treatment for LSCD, including severe cases, because it can provide symptom relief and improve vision. Its customizability, as demonstrated in this study, is beneficial for troubleshooting issues with fitting. Future studies are needed to further assess PROSE as treatment for LSCD.

Prevalence and Characteristics of Dupilumab-Induced Ocular Surface Disease in Adults With Atopic Dermatitis

PURPOSE

Dupilumab-induced ocular surface disease (DIOSD) is a common reaction among patients treated for atopic dermatitis. This study aimed to identify the clinical characteristics, associated risk factors, treatment strategies, and long-term outcomes of DIOSD.

METHODS

We conducted a multicenter retrospective cohort study of consecutive adult outpatients treated with dupilumab for moderate-to-severe atopic dermatitis from 2017 through 2021 at 2 tertiary care centers. We used stepwise multivariable logistic regression to assess the association between patient characteristics and development of DIOSD.

RESULTS

Among 210 patients treated with dupilumab, 37% (n = 78) developed DIOSD over the 52-week follow-up period. Vision-threatening complications including corneal scarring and cicatricial ectropion were noted in 1% (n = 3) of patients. Clinical features were blepharoconjunctivitis (68%, n = 53), burning/stinging/dryness (14%, n = 29), epiphora (13%, n = 10), pruritus (13%, n = 10), blurred vision (3%, n = 2), and photophobia (1%, n = 1). DIOSD was associated with a history of asthma (odds ratio: 2.94, 95% confidence interval: 1.26-6.87, P = 0.01) and a family history of atopic dermatitis (odds ratio: 2.58, 95% confidence interval: 1.08-6.17, P = 0.03). Interventions were initiated for 63% of patients with DIOSD, with artificial tears (56%) and corticosteroid drops (29%) most commonly used. Dupilumab was discontinued because of DIOSD in 4% of patients.

CONCLUSIONS

DIOSD is a common adverse event that is usually mild but may lead to treatment interruption and vision-threatening complications. A personal history of asthma and family history of atopic dermatitis may be associated with a higher risk of developing DIOSD.

Surgical Management of Fuchs Endothelial Corneal Dystrophy: A Treatment Algorithm and Individual Patient Meta-Analysis of Descemet Stripping Only

PURPOSE

This study aims to determine predictive factors for success of Descemet stripping only (DSO) in Fuchs corneal endothelial dystrophy and propose a DSO treatment algorithm.

METHODS

Ovid MEDLINE, Embase, and Cochrane CENTRAL databases were searched to evaluate DSO case series, including combined phacoemulsification and DSO, and the use of Rho-kinase inhibitors (ROC-i). Our primary outcome was success of corneal clearance. Secondary outcomes included the time to corneal clearance, the postoperative endothelial cell count (ECC), and the impact of ROC-i.

RESULTS

Sixty-eight cases were evaluated with a mean follow-up of 12.4 months. DSO corneal clearance was achieved in 85% (n = 58) with a mean time of 4.9 weeks for the ROC-i group compared with 10.1 weeks in the observation group (P < 0.0001). The mean central ECC postoperatively was higher in the ROC-i group compared with the observation group 1151 ± 245 versus 765 ± 169 cells/mm2, respectively (P < 0.018). The postoperative best-corrected visual acuity (BCVA) improved in 61 eyes (90%), with mean final BCVA of 0.17 (0.26) logMAR (P = 0.001), which was statistically significant compared with preoperative BCVA. Factors influencing success were 4-mm descemetorhexis size, a clear peripheral ECC with no clinical sequelae of decompensation or guttae, and a low central corneal thickness. No intraoperative complications were noted. The commonest postoperative complication was deep corneal stromal scars noted at the descemetorhexis edge (n = 9).

CONCLUSIONS

DSO has a role in the treatment of a subset of patients with Fuchs corneal endothelial dystrophy and that adjuvant treatment with ROC-i may lead to faster corneal clearance.

Clinical and microbiological analysis of fungal keratitis in Toronto, Canada: A 20-year study

Fungal keratitis is a devastating and difficult-to-treat ocular infection with high morbidity. Understanding geographic microbiological and clinical trends helps to guide rapid and effective treatment. We therefore report the characteristics and outcomes of fungal keratitis in Toronto, Canada over a twenty-year period. An electronic search of microbiology records at University Health Network, Toronto, ON, Canada identified all patients with positive corneal fungal culture over a 20-year period seen at our tertiary referral cornea practice. Review of corresponding patient charts identified demographic and microbiological details, clinical course, treatment regimen, and final outcomes associated with each episode of culture-positive fungal keratitis. Forty-six patients with fifty-one discrete fungal keratitis episodes were included. Five patients experienced recurrent fungal keratitis. Candida species accounted for 60.8% of positive fungal cultures, followed by Filamentous species at 35.3%. Preferred initial anti-fungal treatment was topical amphotericin at 36.7% followed by topical voriconazole at 32.6%. Surgical intervention was required in 48.9% with therapeutic penetrating keratoplasty being the most common procedure (22.4%). Final visual acuity (VA) of < 20/200 was attributed to 58% of patients in this study. Risk factors for poor outcomes included poor VA, topical steroid use at presentation, Candida involvement, history of ocular surface disease, organic ocular trauma, or prior corneal transplantation. Candida is the most frequent keratomycotic pathogen in Toronto. Risk factors for poor visual outcome include prior corneal transplantation, ocular surface disease/trauma, or pre-existing topical steroid use. Early suspicion, diagnosis and treatment are paramount for best clinical outcomes.

The Effect of COVID-19 on Corneal Donor Volumes and Eye Bank Processes: An Analysis From the Eye Bank of Canada (Ontario Division)

PURPOSE

With the rise in COVID-19 cases, the Eye Bank of Canada (Ontario Division), the largest eye bank in Canada, was faced with challenges related to ocular donor suitability which resulted in tissue shortages after the first wave of COVID-19 cases in Ontario, Canada. This article aims to analyze the impact of COVID-19 on ocular tissue donation and transplant surgeries.

METHODS

Trends in ocular donations in 2020 and the transplant rates were compared with the data from the previous year, as a benchmark of normal eye bank activity.

RESULTS

Ocular donor volumes decreased during the first wave of the COVID-19 pandemic (March-June 2020) by 65% as compared to the same period in 2019. By the end of the year 2020, this had resulted in a total reduction of 29% of ocular donor volumes as compared to 2019. The ocular transplant surgery volumes in the year 2020 decreased by 32% compared to the previous year, mostly secondary to elective surgery shutdown during the first wave. Because of tissue shortages, the Eye Bank of Canada (Ontario Division) had to import 24 corneas from the United States and cancel 7 surgeries in the year 2020.

CONCLUSIONS

The decline in ocular tissue donor volumes and transplant surgery was a result of an interplay of causes related to the COVID-19 pandemic. Most importantly, ruling out of COVID-19 carriers, lockdown measures affecting tissue retrieval processes, and shutdown of elective surgery were the 3 major factors accounting for tissue shortages and surgical volume reductions.

"Smoldering" Rejection of Keratolimbal Allograft

PURPOSE

The purpose of this study was to report a case of "smoldering" keratolimbal allograft (KLAL) rejection in a patient with subtherapeutic levels of systemic immunosuppression in temporal association with BNT162b2 messenger RNA vaccination for severe acute respiratory syndrome coronavirus 2.

METHODS

This was a case report.

OBSERVATIONS

A 72-year-old man presented with circumferential perilimbal engorgement, stagnation, and tortuosity of vessels with mild chemosis in his right eye KLAL segments 1 month after receiving the BNT162b2 messenger RNA vaccine while his tacrolimus trough blood levels were subtherapeutic measuring <2 ng/mL. He had undergone KLAL 6.5 years before for total limbal stem cell deficiency from a chemical injury and had been stable without any history of rejection. The donor was blood type O, and the patient had no systemic comorbidities. The patient was treated with hourly difluprednate 0.05% and increasing of his oral tacrolimus dose to 2 mg twice a day with improvement of rejection signs.

CONCLUSIONS

There may be a temporal association between KLAL rejection after immunization against severe acute respiratory syndrome coronavirus 2 in patients with subtherapeutic levels of systemic immunosuppression. Patients should be on alert for any ocular signs or symptoms postimmunization and present for treatment immediately.

Remote Surgeon Virtual Presence: A Novel Telementoring Method for Live Surgical Training

PURPOSE

We describe the first known use of telementoring in corneal surgery and technology combining a 3-dimensional microscope system, 5G live streaming technology, group chat software, and a virtual reality headset for intercontinental surgical supervision.

METHODS

Three surgeons in Toronto were proctored by a surgeon in Israel in the implantation of a novel keratoprosthesis device (CorNeat KPro; Ra'anana, Israel) into cadaver eyes. In Toronto, the NGENUITY platform (Alcon) transmitted high-definition, 3-dimensional images to the proctor in Israel who viewed the live video through a GOOVIS Virtual Reality headset with subsecond latency. This was made possible by the LiveU technology (Hackensack, NJ), which is a portable device to increase the bandwidth of transmission. The primary outcome was the successful completion of CorNeat KPro implantation. After each procedure, all surgeons completed a Likert scale questionnaire that assessed opinions on telementoring.

RESULTS

All participants implanted the CorNeat KPro device. There was significant satisfaction reported. A total cumulative score from the questionnaire was 149 of 150 from the operating surgeons, with a score of 135 of 150 by the proctor. All felt that there was excellent AV quality with no lag time and recommended the technology.

CONCLUSIONS

Telementoring is a promising tool that can traverse large distances for ophthalmic education.

Phototherapeutic keratectomy versus epithelial debridement combined with anterior stromal puncture or diamond-dusted burr for treatment of recurrent corneal erosions

OBJECTIVE

To compare outcomes of phototherapeutic keratectomy (PTK) versus epithelial debridement combined with anterior stromal puncture (ASP) or diamond burr for the treatment of recurrent corneal erosions (RCES) in a large tertiary centre.

METHODS

Patients with a diagnosis of RCES secondary to trauma or epithelial basement membrane dystrophy who underwent a surgical procedure between 2009 and 2019 were included in the study. The following data were collected: demographics, ocular history, prior medical treatment, ocular surgeries, intervention, complete epithelialization at postoperative week 1, recurrences, and complications. Recurrence was defined as either an objective finding of a corneal epithelial defect or symptoms suggestive of recurrent epithelial erosion on history. Recurrence rate and time to epithelialization were compared between groups.

RESULTS

A total of 97 eyes (73 patients) were included in the study. Mean patient age was 51 ± 16.1 years, and mean follow-up was 474 days. RCES was secondary to epithelial basement membrane dystrophy in 80% (n = 78 of 97), trauma (15%, n = 15 of 97), or idiopathic (4%, n = 4 of 97). Epithelial debridement with ASP was performed in 34 eyes (35%), diamond burr in 33 eyes (33%), and PTK in 30 eyes (31%). Compared with epithelial debridement with ASP (recurrence 29.4%), the recurrence rate was significantly lower for both the diamond burr (9.1%, p = 0.031) and PTK groups (10%, p = 0.048). The diamond burr and PTK groups also had a significantly higher rate of complete epithelialization at 1 week (p < 0.05).

CONCLUSION

Compared with epithelial debridement with ASP, diamond burr and PTK have significantly lower rates of recurrence and time to epithelialization and may be considered first for surgical management of RCES.

Comparative evaluation of four Descemet membrane endothelial keratoplasty graft preparation techniques

OBJECTIVE

To compare subjective and objective outcomes of 4 different Descemet membrane endothelial keratoplasty (DMEK) peeling techniques performed by novice surgeons at different stages in their surgical career.

DESIGN

An ex vivo prospective study.

METHODS

In the first round, 2 DMEK peeling techniques were pitched against each other: the peripheral scoring and Sinskey dissection technique with the peripheral scoring and microhoe dissection and the peripheral blunt microhoe dissection against the scleral spurectomy and microhoe dissection. Three surgeons with different operative experience performed the peeling. Outcome measures included graft peeling time, surgeon's peeling difficulty grading (on a scale of 1-10, 1 being the easiest and 10 the hardest), number of radial and circumferential tears before and after trephination, and tissue loss. The 2 techniques that performed the best from the first round proceeded to the final round to identify the best overall technique.

RESULTS

In total, 90 tissues (45 pairs) were peeled by 3 surgeons. Following the first-round results, the peripheral scoring and Sinskey dissection and peripheral blunt microhoe dissection proceeded to the final round. There were no significant differences between the groups in terms of peeling times, subjective feeling of difficulty, post-trephination tears, and peeling success rates (P > 0.05 for all). However, the peripheral scoring and Sinskey dissection technique had significantly fewer pretrephination radial tears (1.3 ± 1.3 vs 6.1 ± 5.2, P = 0.007) and circumferential tears (0.6 ± 0.9 vs 1.8 ± 2.1, P = 0.02).

CONCLUSIONS

This study demonstrates that the learning curve can be overcome quickly with appropriate DMEK peeling techniques. The peripheral scoring and Sinskey dissection peeling technique allows efficient peeling with fewer related tears.

Posterior lamellar keratoplasty: techniques, outcomes, and recent advances

Over the past 2 decades, posterior lamellar keratoplasty (PLK) has emerged as an alternative to penetrating keratoplasty in the treatment of corneal endothelial disorders. The reasons for this trend include the search for a safer procedure to replace diseased endothelium that provides faster and better visual rehabilitation and reduces the need for postoperative care. Different surgical techniques, surgical instruments, devices, and lasers have been introduced to overcome technical difficulties, thus improving clinical outcomes. Yet, surgeons and eye banks must address the complications and limitations that arise during the transition to these new techniques. This review discusses the most significant aspects of the evolution of PLK, including a detailed description of current techniques and the direction of future treatment for corneal endothelial disease with the use of laser-assisted surgery, bioengineered corneas, cell therapy, and new pharmacologic therapy.

Four-Year Survival Comparison of Endothelial Keratoplasty Techniques in Patients With Previous Glaucoma Surgery

PURPOSE

To compare 4-year survival outcomes of Descemet membrane endothelial keratoplasty (DMEK) and Descemet-stripping automated endothelial keratoplasty (DSAEK) in eyes with previous glaucoma surgery.

METHODS

This is a retrospective, comparative case series, including patients with previous trabeculectomy or glaucoma drainage device implantation, who later underwent either DMEK (n = 48) or DSAEK (n = 41). Follow-up was limited to 12 to 60 months to prevent bias. Primary outcomes were graft survival and rejection. Secondary outcomes were best spectacle-corrected visual acuity (BSCVA), detachment/rebubble, endothelial cell loss, and intraocular pressure elevations.

RESULTS

Baseline characteristics, follow-up duration, and preexisting glaucoma parameters did not differ significantly between the groups. Graft survival probability after DMEK and DSAEK was 75% and 75% at 1 year, 63% and 50% at 2 years, 49% and 44% at 3 years, 28% and 33% at 4 years, and 28% and 29% at 5 years, respectively (P = 0.899 between the groups). Graft rejection rates were 20.8% and 19.5%, respectively (P = 1.000). Primary failure, rebubbling, endothelial cell loss, and intraocular pressure elevation did not differ significantly between the groups. Preoperative BSCVA did not differ between the groups (P = 0.821). Postoperative BSCVA was significantly better in the DMEK group at 6, 12, and 24 months (P < 0.001, P = 0.022, and P = 0.047, respectively). In a multivariable model (R2 = 0.576), the type of surgery was the only significant factor affecting postoperative BSCVA, in favor of DMEK (coefficient value -0.518, P = 0.002).

CONCLUSIONS

In eyes with previous glaucoma surgery, DMEK and DSAEK had comparably low survival and comparably high rejection rates. Postoperative visual acuity might be better after DMEK in this setting.

The corneal endothelium: clinical review of endothelial cell health and function

The endothelial cell is a critical structure within the cornea and is responsible for maintaining corneal clarity through its pump function. Endothelial cells are lost over time naturally but can be injured medically, surgically, or as a part of various dystrophies. Monitoring of endothelial cells can be performed clinically or more formally with specular microscopy. In cases of significant compromise, endothelial cells can be transplanted by various endothelial keratoplasty techniques. The future pipeline is bright for possible endothelial cell regeneration and rehabilitation. This article reviews these topics in depth to provide a comprehensive look at the structure and function of the endothelial cell, etiologies of endothelial cell damage, detailed review of iatrogenic causes of endothelial cell loss, and management strategies.

Comparison of manual and femtosecond astigmatic keratotomy in the treatment of postkeratoplasty astigmatism

PURPOSE

To compare the outcomes of femtosecond astigmatic keratotomy (FSAK) and manual astigmatic keratotomy (AK) in treatment of postkeratoplasty astigmatism.

METHODS

A retrospective, comparative, pairwise-matched case series including 150 patients who underwent either FSAK (n = 75) or manual AK (n = 75) for the treatment of astigmatism (>3.00 D) following penetrating keratoplasty or deep anterior lamellar keratoplasty. Pairwise matching for baseline variables (age, visual acuity and astigmatism) was performed.

RESULTS

Mean age was 57.5 ± 16.0 years. The FSAK group had significantly better postoperative best-corrected visual acuity (BCVA) (p = 0.010), uncorrected visual acuity (UCVA) (p = 0.049), corneal astigmatism (p = 0.020) and manifest astigmatism (p < 0.001) compared with the manual AK group. Gain of ≥3 lines in BCVA (logMAR) was seen in five eyes (6.7%) and 21 eyes (28.0%) in manual AK and FSAK, respectively (p = 0.005). Alpins vector analysis showed lower (closer to 0) index of success (0.50 ± 0.24 and 0.79 ± 0.48, p < 0.001) and higher (closer to 1) correction index (0.94 ± 0.45 and 0.74 ± 0.55, p = 0.020) in FSAK compared with manual AK. Corneal and manifest astigmatism improved significantly in both groups, while BCVA and UCVA improved significantly in FSAK only. Repeat AK rate was 32% (24 eyes) in manual AK and 4% (three eyes) in FSAK (p < 0.001). Overcorrection-related re-suturing rate was 0% in manual AK and 8% (six eyes) in FSAK (p = 0.037). There was one microperforation (1.3%) in FSAK, and there were no occurrences of graft dehiscence, infectious keratitis or graft rejection.

CONCLUSIONS

Both manual AK and FSAK were safe and effective in reducing postkeratoplasty astigmatism. FSAK had superior visual and keratometric outcomes compared with manual AK.

Risk Factors for Repeat Descemet Membrane Endothelial Keratoplasty Graft Failure

PURPOSE

To evaluate repeat Descemet membrane endothelial keratoplasty (re-DMEK) success rates and to identify risk factors for re-DMEK failure.

DESIGN

Retrospective case series.

METHODS

Settings: Institutional.

PATIENTS AND INTERVENTIONS

A chart review was performed, including all eyes with primary DMEK failure that underwent re-DMEK between 2013 and 2019 at the Toronto Western Hospital and the Kensington Eye Institute (Toronto, Ontario, Canada) and had at least 6 months of follow-up.

MAIN OUTCOME MEASURE

Predicting factors for re-DMEK outcome.

RESULTS

Of 590 consecutive DMEK surgeries, 40 eyes (6.7%) were identified for having a secondary DMEK surgery after primary DMEK failure. Etiologies for primary DMEK were Fuchs endothelial corneal dystrophy (32.5%), pseudophakic bullous keratopathy (35%), previous failed graft (27.5%), and other indications (5%). Fifty-five percent of the cohort were categorized as having a complicated anterior segment including 11 eyes with previous glaucoma surgery, 7 eyes post-penetrating keratoplasty, 4 eyes post-Descemet stripping automated endothelial keratoplasty, 3 eyes peripheral anterior synechia, 3 eyes previous pars plana vitrectomy, 2 eyes aphakia, and 1 eye each with aniridia, anterior chamber intraocular lens, and iris-fixated intraocular lens. Re-DMEK failure was documented in 12 eyes (30%) of the entire cohort. The risk factor for re-DMEK failure was the presence of a complicated anterior segment (P = .01, odds ratio = 17.0 [95% confidence interval: 1.92-150.85]), with 50% re-DMEK failure rate in this subgroup.

CONCLUSION

Re-DMEK is a viable option for cases of primary DMEK failure, especially for eyes with Fuchs endothelial corneal dystrophy as the indication for primary DMEK without other ocular morbidities; however, eyes categorized with a complicated anterior segment had high re-DMEK failure rates.</ABSTRACT>.

A National Consensus Forum on improving cornea donation and transplantation access in Canada

A consensus meeting was held in Toronto on February 9–10, 2020 to discuss ways to improve cornea donation and transplantation access in Canada. The meeting brought together eye and tissue bank representatives, health authority and hospital leadership, transplant ophthalmologists, organ donation organizations, transplant recipients, donor families and several national organizations. Through facilitated discussions in multidisciplinary, gender-balanced, and geographically balanced small groups, participants identified opportunities for improvement in the Canadian cornea donation and transplantation system. Discussion occurred around broad themes of donor tissue demand, supply, access, utilization, interprovincial sharing and cost recovery, interprovincial knowledge sharing and research. This event marked the first time in 10 years in which the Canadian cornea transplantation community came together.

Sutureless dehydrated amniotic membrane for persistent epithelial defects

PURPOSE

To report outcomes of a sutureless dehydrated amniotic membrane for persistent epithelial defects (PED).

METHODS

This retrospective study included consecutive patients with a PED (⩾14 days) treated with a sutureless dehydrated amniotic membrane and bandage contact lens (BCL). Included were patients with an epithelial defect that did not respond to treatment with a BCL. Excluded were patients with a follow-up time of less than 3 months.

RESULTS

Nine eyes of eight patients with a mean age of 54.6 ± 10.9 years (range 38-73 years) were included in this study. The main etiology of the PED was limbal stem cell deficiency (n = 5/9) due to Stevens-Johnson Syndrome (n = 2/5), glaucoma procedures (n = 1/5), graft-versus-host disease (n = 1/5) and severe allergic reaction (n = 1/5). Additional etiologies included neurotrophic cornea (n = 2/9), post keratoplasty and severe dry eye disease (n = 2/9). Time from PED presentation to amnion treatment was 65.9 ± 60.6 days (range 15-189 days) with the area of the PED being 11.0 ± 12.2 mm2 (range 1.0-36.0 mm2). The amnion was absorbed within 2 weeks in 100% of the cases. Following insertion of the amnion, resolution of the PED was achieved in 8/9 eyes (89%) without the need for additional interventions within 17.8 ± 9.6 days (range 7-35 days). LogMAR BCVA improved from 0.94 ± 0.88 to 0.37 ± 0.25 (p = 0.036) with no complications or recurrences recorded.

CONCLUSIONS

Sutureless dehydrated amniotic membrane achieved resolution of PEDs secondary to various etiologies in 89% of eyes with a significant improvement in vision demonstrated. Further studies are needed to assess long term safety and effectiveness.

SARS-CoV-2 Not Detectable in Ocular Specimens of a Patient with a Past Infection

Purpose: To present a a case study that aims to investigate the presence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the ocular tissue samples of a patient previously infected with COVID-19 and determine its transmissibility.Study Design: Case ReportResults: In this case study, SARS-CoV-2 was not detected in the vitreous and uveal tissue samples by RT-PCR for detection of three gene targets in a patient with a past COVID-19 infection 15 days prior to presention with a globe rupture.Conclusions: Our findings suggest that patients with long-term existence of SARS-CoV-2 at low detectable levels may not have active intraocular viral shedding. This is of particular importance as ophthalmic surgical procedures may potentiate virus spread from patients infected with SARS-CoV-2.

Descemet Membrane Endothelial Keratoplasty versus Descemet Stripping Automated Endothelial Keratoplasty in Complicated Vitrectomized Eyes

PURPOSE

Vitrectomized eyes pose a technical challenge when performing endothelial keratoplasty (EK). The aim of the study was to compare outcomes of Descemet membrane endothelial keratoplasty (DMEK) and Descemet stripping automated endothelial keratoplasty (DSAEK) in complex eyes undergoing pars plana vitrectomy (PPV) prior to or during surgery.

METHODS

This retrospective study included consecutive eyes that underwent pars plana infusion-assisted DMEK or pull-through DSAEK which underwent PPV prior to or during the EK at a tertiary center. Included were eyes with at least 1-year follow-up. The main outcome measures were best-corrected visual acuity (BCVA) and serious adverse events.

RESULTS

Fifty-two eyes (n = 52) with a mean follow-up time of 24.6 ± 7.4 months were included. Both groups were similar in terms of baseline characteristics although the DMEK group had a significantly larger proportion of Fuchs' patients (p = .009). There was no significant difference in postoperative logMAR BCVA between groups at each visit (p > .05 for all). There was a significantly higher proportion of overall serious adverse events (50.0% versus 15.4%, p = .02), retinal detachments (19.2% versus 0.0%, p = .05) and cystoid macular edema (23.1% versus 0.0%, p = .02) following DMEK. Graft detachment occurred more often following DMEK (53.9% versus 11.5%, p = .001) with no significant difference in rebubbling rates (23.1% versus 11.5%, p = .27).

CONCLUSIONS

A significant and similar improvement in BCVA was achieved following DMEK and DSAEK in complex vitrectomized eyes. Patients should be advised regarding the higher rates of potential serious complications associated with a pars plana infusion DMEK in this situation.

Surgical Management of the Ocular Surface in Neurotrophic Keratopathy: Amniotic Membrane, Conjunctival Grafts, Lid Surgery, and Neurotization

PURPOSE

To review the surgical modalities available to treat Mackie stage 2 and stage 3 neurotrophic keratopathy.

METHODS

Literature review and technique descriptions.

RESULTS

The following procedures are described in detail with accompanying videos: temporary, permanent, and botox-assisted tarsorrhaphy; amniotic membrane transplant; keratoplasty with amniotic membrane and tarsorrhaphy augmentation; Gunderson and conjunctival pedicle flaps; buccal graft transplantation; and neurotization.

CONCLUSION

A variety of surgical options exist to manage neurotrophic keratopathy when medical treatments alone fail to resolve epitheliopathy. Ongoing protection and optimization of the ocular surface health remains crucial to prevent recurrent epithelial breakdown.

Assessment of response to multimodal management of neurotrophic corneal disease

PURPOSE

To characterize patients with neurotrophic keratopathy (NK) and describe treatment outcomes.

METHODS

Setting: Two institutional tertiary cornea clinics.

PATIENTS

Medical record review of 37 consecutive patients (37 eyes) with NK.

INTERVENTION

Management of NK.

MAIN OUTCOME MEASURES

Best-corrected visual acuity (BCVA), epithelial defects (ED), re-epithelialization time, number of perforations, need for penetrating keratoplasty and tarsorrhaphy.

RESULTS

Average age was 64.4 ± 15.0 years, with 59.5% male patients. Average follow up time was 20.8 ± 32.6 months. Moderate to severe NK (Mackie Stage) was present in 62.1% of patients. Herpetic, neurosurgical and pars plana vitrectomy were the top three causes in each Mackie Stage. 72.9% used topical steroids to treat inflammatory ocular disease. Mean number of EDs was 1.6 per patient averaging 85 days to heal. Persistent EDs affected 56.7%. Corneal perforation (18.9%) was more likely with advanced age, herpetic cause and Stage 3 presentation. Tarsorrhaphy was performed in 35% of patients and were more likely with Stage 3 presentation. Referral for neurotization occurred in 10.8%. Evisceration was required in 2 eyes. BCVA of 20/40 or better was achieved in 21.6% of eyes at last follow up.

CONCLUSIONS

NK is chronic, frequently visually disabling with multiple contributing factors requiring different treatment modalities. Herpetic, pars plana vitrectomy and neurosurgical causes constitute a significant proportion of NK. Persistent epithelial defects should be rapidly managed as corneal perforation is a serious complication. Advanced age, herpetic cause and Mackie Stage 3 at diagnosis are significant risk factors for corneal perforation.

An algorithm for the preoperative diagnosis and treatment of ocular surface disorders

Any ocular surface disease (OSD), but most commonly, dry-eye disease (DED), can reduce visual quality and quantity and adversely affect refractive measurements before keratorefractive and phacorefractive surgeries. In addition, ocular surgery can exacerbate or induce OSD, leading to worsened vision, increased symptoms, and overall dissatisfaction postoperatively. Although most respondents of the recent annual American Society of Cataract and Refractive Surgery (ASCRS) Clinical Survey recognized the importance of DED on surgical outcomes, many were unaware of the current guidelines and most were not using modern diagnostic tests and advanced treatments. To address these educational gaps, the ASCRS Cornea Clinical Committee developed a new consensus-based practical diagnostic OSD algorithm to aid surgeons in efficiently diagnosing and treating visually significant OSD before any form of refractive surgery is performed. By treating OSD preoperatively, postoperative visual outcomes and patient satisfaction can be significantly improved.

"Basket" mattress suture to manage positive vitreous pressure during penetrating keratoplasty

OBJECTIVE

To describe a new/modified technique to manage posterior vitreous pressure (PVP) during penetrating keratoplasty (PKP) and report a small series.

DESIGN

Retrospective interventional case series and technique description.

PARTICIPANTS

PKP eyes necessitating mattress suture placement owing to PVP.

METHODS

Retrospective chart review from 2016 to 2019 was undertaken. Placed prophylactically (before trephination) or after trephination, the mattress suture is placed limbus-to-limbus across the anterior chamber. A second mattress suture can be placed in the opposite meridian (perpendicularly) for added support (safety basket configuration). Variations of suture technique are described based on lens status (i.e., phakic, pseudophakic, aphakic) and intraoperative timing. Parameters assessed included demographics, lens status, suture indications, intraoperative technique details, successful PKP completion, and presence of primary failure.

RESULTS

There were 6 phakic eyes (5 patients) and 9 pseudophakic/aphakic eyes (8 patients). Indications for the phakic subgroup were obesity (83%), poor scleral rigidity (83%), repeated iris prolapse (67%), dense mature cataract (33%), and planned large-diameter PKP (33%). Indications for pseudophakic/aphakic eyes included intraocular lens/iris prolapse (100%), pre-existing iris defects (67%), and planned large-diameter PKP (33%). Successful PKP was performed in all cases. Whereas one case had residual corneal edema in the setting of a persistent epithelial defect owing to limbal stem cell deficiency, all other cases demonstrated no primary graft failure.

CONCLUSIONS

Although increased PVP can present a stressful and challenging situation, it is important to have multiple options for management. This simple mattress suture technique normalizes the lens-iris complex behaviour and appears safe for the donor graft.

Lifitegrast Ophthalmic Solution 5.0% for Treatment of Dry Eye Disease: Overview of Clinical Trial Program

Dry eye disease (DED) is a common inflammatory disorder of the ocular surface. Millions of people are affected by DED worldwide. Lifitegrast is a novel drug designed to inhibit DED-associated ocular inflammation. Four clinical trials have shown that lifitegrast is well tolerated and effective in improving symptoms and signs of DED over 12 weeks. A fifth trial showed long-term safety over 1 year. Lifitegrast has been in clinical use for more than one year in the United States and was recently approved in Canada (in December 2017). In this review, we discuss lifitegrast's novel mechanism of action and provide an overview of its clinical trial program.

Descemet membrane endothelial keratoplasty in patients with prior glaucoma surgery

OBJECTIVE

To present outcomes of Descemet membrane endothelial keratoplasty (DMEK) in eyes with prior trabeculectomy or a glaucoma drainage device (GDD).

METHODS

A retrospective case series, including patients that had previously undergone trabeculectomy and/or GDD implantation, who later underwent DMEK between 2013 and 2016 at Toronto Western Hospital and the Kensington Eye Institute. Outcome measures: best spectacle-corrected visual acuity (BSCVA), endothelial cell (EC) density, intraoperative and postoperative complications.

RESULTS

Twenty-seven eyes of 27 patients were included. All DMEK procedures were uneventful. Mean follow-up time was 14.6 ± 6.1 months. In eyes with no visually limiting comorbidities (n = 16), BSCVA improved from 1.34 ± 0.65 logMAR (Snellen equivalent ~20/440) preoperatively to 0.51 ± 0.24 logMAR (Snellen equivalent ~20/65) and 0.50 ± 0.33 logMAR (Snellen equivalent ~20/65) at 6 and 12 months, respectively (p < 0.001 for both). In eyes with visually limiting comorbidities (n = 11), BSCVA improved from 1.92 ± 0.72 logMAR (Snellen equivalent ~20/1665) preoperatively to 1.43 ± 0.83 logMAR (Snellen equivalent ~20/540) and 1.37 ± 0.99 logMAR (Snellen equivalent ~20/470) at 6 and 12 months, respectively (p = 0.008 and p = 0.037).Graft detachment rate was 24.1% and rebubble rate was 17.2%. Primary and secondary graft failure rates were 3.7% and 10.3%, respectively. Rejection rate was 17.2%. EC-loss rate at 6 months and 12 months was 36.7% and 50.5%, respectively.

CONCLUSIONS

DMEK performed in eyes with previous trabeculectomy or a GDD is more challenging than conventional DMEK, but has good outcomes. Higher rates of graft rejection and secondary graft failure in this setting should be further evaluated in long-term studies.

Comparison of Manual and Femtosecond Laser-Assisted Descemet Membrane Endothelial Keratoplasty for Failed Penetrating Keratoplasty

PURPOSE

To compare outcomes of manual Descemet membrane endothelial keratoplasty (M-DMEK) and femtosecond laser-assisted Descemet membrane endothelial keratoplasty (F-DMEK) in treatment of penetrating keratoplasty (PK) graft failure.

METHODS

Setting: Retrospective, interventional comparative case series. PatientPopulation: Included were all patients with a failed PK graft who underwent either F-DMEK (10 eyes of 10 patients) or M-DMEK (29 eyes of 29 patients) at Toronto Western Hospital and the Kensington Eye Institute between 2014 and 2019, and had 6 months of postoperative follow-up. OutcomeMeasures: Rates of graft detachment, rebubbling, rejection and failure, best spectacle-corrected visual acuity (BSCVA), and endothelial cell (EC) density.

RESULTS

Rate of significant graft detachment (detachment requiring either rebubble or repeat keratoplasty) was 10.0% in F-DMEK and 65.5% in M-DMEK (P = .003). Rebubble rate was 10.0% in F-DMEK and 58.6% in M-DMEK (P = .011). Primary failure rate was 0% in F-DMEK and 27.6% in M-DMEK (P = .086). Rates of rejection and secondary failure did not differ between the groups (P = 1.000 for both). In a multivariable analysis, F-DMEK was found to be the only independent factor significantly associated with reduced postoperative detachment. Postoperative BSCVA at 6 months returned to prefailure levels in both groups, with no significant difference between the groups at any time point. EC loss rates were 43.8% in F-DMEK and 38.0% in M-DMEK at 6 months (P = .453).

CONCLUSIONS

F-DMEK is a safe and effective procedure in failed PK patients, with outcomes comparable to M-DMEK, and with reduced detachment and rebubble rates. A trend towards reduced primary failure should be further studied.

Accelerated Corneal Cross-Linking: Efficacy, Risk of Progression, and Characteristics Affecting Outcomes. A Large, Single-Center Prospective Study

PURPOSE

We examined the efficacy and preoperative characteristics that affect outcomes of accelerated (9 mW/cm² for 10 minutes) corneal cross-linking (CXL).

DESIGN

Prospective single-center observational cohort study.

METHODS

We enrolled 612 eyes of 391 subjects with progressive keratoconus (n = 589), pellucid marginal degeneration (n = 11), and laser in situ keratomileusis-induced ectasia (n = 12). We evaluated best spectacle-corrected visual acuity (BSCVA), topography, refraction, endothelial cell density, corneal thickness, haze, intraocular pressure, and visual function before and 12 months after the CXL procedure. We tabulated the proportion of those with progression of maximum keratometry (Kmax). We included participant's race, age, sex, and the presence of preoperative apical scarring and environmental allergies in a multivariable linear regression model to determine the effect of these characteristics on outcomes.

RESULTS

At 1 year there was no significant change in mean Kmax (n = 569). Progression of Kmax was higher in subgroups with a baseline Kmax >58 diopters (n = 191) and those 14-18 years of age (n = 53). Preoperative BSCVA, Kmax, refraction, corneal cylinder, coma, central corneal thickness, and vision function were statistically and clinically significant predictors of outcomes (P < .001). Preoperative apical scarring led to worsening haze (P = .0001), more astigmatism (P = .002), more central corneal thinning (P = .002), and was protective to the endothelium (P = .008). Race, age, and sex affected some outcomes.

CONCLUSION

Mean Kmax was stable at 1 year after accelerated CXL. Younger patients and those with a higher preoperative Kmax need to be monitored closely for progression. Preoperative BSCVA, topography, refraction, CCT, and apical scarring were significant predictors of outcomes.