Double-Bubble Technique Assisted by Holding Forceps: A Modified Technique in Descemet Membrane Endothelial Keratoplasty for Vitrectomized Eyes With Scleral Fixated Intraocular Lens

PURPOSE

Several techniques have been developed for graft unfolding approaches in Descemet membrane endothelial keratoplasty (DMEK). However, despite these techniques, graft deployment and configuration in eyes with deep anterior chambers remain challenging in some cases. Therefore, in this study, we described a modified technique for DMEK, known as the "double-bubble technique assisted by holding forceps."

METHODS

This was a retrospective interventional case series. Patients who underwent DMEK between August 2022 and July 2023, including cases with a history of vitrectomy and scleral fixation of intraocular lens, were enrolled in this study. Two experienced surgeons performed DMEK. In brief, after graft insertion into the anterior chamber, the first bubble with a small volume of air was injected above the graft to open the tight roll, and the graft edge was held using a 25-gauge graft manipulator. The second bubble was injected underneath the graft for fixation, while the graft edge was grasped using forceps during gas injection. The graft was released from the forceps. Best spectacle corrected visual acuity, central corneal thickness, endothelial cell density, and incidence of postoperative complications were measured before and after DMEK.

RESULTS

Eleven eyes of 11 patients were included in this study (mean follow-up period, 4.5 ± 4.4 months). Best spectacle corrected visual acuity and central corneal thickness significantly improved postoperatively ( P < 0.001). Rebubbling was required in 2 eyes; no other postoperative complications or primary graft failure were observed.

CONCLUSIONS

The present technique enables safe and feasible DMEK surgery in vitrectomized eyes with scleral fixated IOLs and in those with a deep anterior chamber.

Glaucoma-related Risk Factors for Endothelial Cell Loss and Graft Failure After Descemet's Stripping Automated Endothelial Keratoplasty

PRECIS

Previous trabeculectomy and medical or surgical glaucoma treatment after Descemet's stripping automated endothelial keratoplasty were significantly associated with endothelial cell loss and graft failure. Pupillary block was a significant risk factor for graft failure.

PURPOSE

To evaluate the long-term risk factors associated with postoperative endothelial cell loss and graft failure after Descemet's stripping automated endothelial keratoplasty (DSAEK) in Japanese eyes, with special attention to glaucoma.

METHODS

This retrospective study involved 117 eyes of 110 consecutive patients with bullous keratopathy who had undergone DSAEK. The patients were classified into four groups: no glaucoma group (n=23 eyes), primary angle-closure disease (PACD) group (n=32 eyes), glaucoma group that had previously undergone trabeculectomy (n=44 eyes) (glaucoma with bleb), and glaucoma group that had not previously undergone trabeculectomy (n=18 eyes) (glaucoma without bleb).

RESULTS

The cumulative 5-year graft survival rate was 82.1%. The cumulative 5-year graft survival rate among the four groups are as follows: no glaucoma (73%), PACD (100%), glaucoma with bleb (39%), and glaucoma without bleb (80%). Multivariate analysis revealed that additional glaucoma medication and glaucoma surgery after DSAEK were independent risk factors for endothelial cell loss. Conversely, glaucoma with blebs and pupillary block were independent risk factors for graft failure after DSAEK.

CONCLUSION

Previous trabeculectomy and medical or surgical glaucoma treatment after DSAEK were significantly associated with endothelial cell loss and graft failure. Pupillary block was a significant risk factor for graft failure.

Clinical Features of Glaucoma Associated with Cytomegalovirus Corneal Endotheliitis

Purpose

Methods

Results

Conclusion

Intraoperative optical coherence tomography-guided nanothin Descemet stripping automated endothelial keratoplasty in a patient with a remarkably thickened cornea

Purpose

To report use of intraoperative optical coherence tomography (OCT) for nanothin Descemet stripping automated endothelial keratoplasty (DSAEK) in a patient with an extremely thickened cornea due to advanced bullous keratopathy.

Observations

A 90-year-old woman with a history of multiple trabeculectomies was referred to us for treatment of advanced bullous keratopathy (1400 μm central corneal thickness). Nanothin DSAEK was planned and performed. In brief, after the removal of the loose corneal epithelium, the anterior chamber was meticulously observed using a surgical microscope and oblique light via an endoillumination probe; however, the visibility of the anterior chamber was limited because of severe corneal edema. Subsequently, a nanothin (47 μm) DSAEK graft stained with trypan blue was inserted into the anterior chamber using an NS endoinserter. Intraoperative OCT was used successfully to visualize the graft unfolding, air tamponade, and graft attachment. At 3 months postoperatively, significant corneal clearing (625 μm central corneal thickness), improvement of visual acuity (decimal 0.04), and pain relief were obtained.

Conclusions and importance

Intraoperative OCT is useful for nanothin DSAEK even when the surgical microscope view is compromised by a remarkably thickened host cornea due to advanced bullous keratopathy. As an alternative to a penetrating keratoplasty, less invasive nanothin DSAEK was successfully performed.

Long-term outcomes of Descemet stripping automated endothelial keratoplasty for bullous keratopathy after argon laser iridotomy

PURPOSE

To report the long-term outcomes of Descemet stripping automated endothelial keratoplasty (DSAEK) for bullous keratopathy secondary to argon laser iridotomy (BK-ALI).

STUDY DESIGN

Retrospective chart review.

METHODS

Forty-five eyes from 41 consecutive patients with BK-ALI who underwent DSAEK from July 2007 to December 2013 were retrospectively analyzed. Best spectacle-corrected visual acuity (BCVA), endothelial cell density (ECD), and any complications were investigated over a 10-year postoperative period.

RESULTS

The mean BCVA improved from 0.80 logMAR before DSAEK to 0.28 logMAR at 6 months after DSAEK; the mean values showed an additional slight improvement between 6 months and 10 years after the surgery (P < .01). The mean ECD decreased from 2864 cells/mm² at baseline to 2269 cells/mm² (20.8% loss) at 6 months post-DSAEK, and this decreasing trend continued throughout the 10 years after DSAEK (P < .01). The mean ECD was 1148 cells/mm² (59.9% loss) after 5 years, and 568 cells/mm² (80.2% loss) after 10 years. No graft deaths were observed throughout the 10-year period (5-year follow-up rate 60.0%, 10-year follow-up rate 20.0%).

CONCLUSIONS

The 10-year outcomes of DSAEK for BK-ALI were excellent with a high graft survival rate.

Graft Edge Reflection of a Tightly Scrolled Roll Using Endoillumination as a Simple Method for Determining Graft Orientation in Descemet Membrane Endothelial Keratoplasty

PURPOSE

To describe a simple finding that can be used to determine donor tissue orientation in Descemet membrane endothelial keratoplasty (DMEK). This involves the appearance of a highly reflective round curved line from an overlapping graft edge within the anterior chamber using light from an endoilluminator. We here name this Kobayashi sign (K-sign).

METHODS

Twelve consecutive eyes from 12 patients who underwent DMEK were evaluated for the presence of a K-sign. The presence of Berrospi sign (B-sign), a double-line reflection from the peripheral curls of the Descemet membrane (DM) roll that has been reported to be useful for correct graft orientation, was also evaluated.

RESULTS

Of 12 cases, 3 donors showed a loosely scrolled roll soon after DM donor insertion; all 3 of these showed a positive B-sign only when the endoilluminator was used. Nine donors showed a tightly scrolled DM roll without a B-sign; among these 9 donors, a K-sign was visible in 7 cases only when the endoilluminator was used. The remaining 2 cases with a tight scroll configuration showed no K-sign even with the use of endoillumination, indicating that the roll edge was located completely downward; rotation of the roll using a small jet of fluid from paracentesis revealed K-sign in these cases.

CONCLUSIONS

This technique is useful for determining the correct orientation of a tightly scrolled DM roll, subsequently enabling rapid DMEK surgery. For loosely scrolled DM roll, endoillumination enhanced B-sing is proven useful.

In vivo Imaging of Reis-Bücklers and Thiel-Behnke Corneal Dystrophies Using Anterior Segment Optical Coherence Tomography

Purpose

To investigate in vivo corneal changes of genetically confirmed Reis–Bücklers corneal dystrophy (RBCD) and Thiel–Behnke corneal dystrophy (TBCD) using anterior segment optical coherence tomography (AS-OCT).

Design

A single-center, prospective, comparative case series.

Methods

Seven patients from 3 pedigrees (3 males, 4 females) with RBCD [Arg124Leu (R124L) heterozygous missense mutation of human transforming growth factor beta-induced (TGFBI) gene] and 4 patients from 3 pedigrees (3 males, 1 female) with TBCD [Arg555Gln (R555Q) heterozygous missense mutation of TGFBI gene] were examined. Six patients with RBCD and three patients with TBCD exhibited recurrence after corneal surgery including penetrating keratoplasty, phototherapeutic keratectomy, and electrolysis. All patients were examined by slit-lamp biomicroscopy followed by AS-OCT. Selected AS-OCT images of the cornea were evaluated qualitatively for changes in shape and degree of light reflection of corneal deposits.

Results

Slit-lamp biomicroscopy showed characteristic irregular gray opacities in Bowman’s layer in each dystrophy: a geographic pattern in RBCD and a honeycomb pattern in TBCD. In each dystrophy, distinct characteristic deposits were observed by AS-OCT as a banding lesion in Bowman’s layer and its adjacent epithelium/stroma. In RBCD, the banding lesion was highly reflective and sharply margined at the stroma. In contrast, deposits in TBCD in the same layer showed a saw-tooth pattern toward the epithelium and poorly margined at the stroma.

Conclusion

AS-OCT is able to clearly identify characteristic in vivo corneal microstructural changes associated with RBCD and TBCD. As a result, in vivo differentiation of RBCD and TBCD can be achieved.

<p>Visibility of the Retina Through an Air-Filled Anterior Chamber During Simultaneous Vitrectomy and Descemet’s Stripping Automated Endothelial Keratoplasty</p>

Purpose

Methods

Results

Conclusion

Factors associated with endothelial cell density loss post Descemet membrane endothelial keratoplasty for bullous keratopathy in Asia

PURPOSE

To investigate the factors associated with endothelial survival after Descemet's membrane endothelial keratoplasty (DMEK) in eyes of Asian patients with bullous keratopathy (BK).

METHODS

In this retrospective, consecutive interventional case series, 72 eyes of 72 patients who underwent DMEK were evaluated. Best corrected visual acuity (BCVA) and corneal endothelial cell density (ECD) were assessed at 12 months postoperatively. Multiple regression analysis was performed to assess parameters such as age, sex, axial length, preoperative visual acuity, re-bubbling, the ratio of graft to cornea area, iris damage scores, types of filling gases, air or SF6 volume in the anterior chamber (AC) on postoperative day 1, and ECD loss rates at 12 months postoperatively.

RESULTS

BCVA improved significantly at 12 months after DMEK (P < .001). The rate of ECD loss at 12 months after DMEK was 54.4 ± 16.1%. Multiple linear regression analysis showed that a larger ratio of graft to corneal area (P = 0.0061) and higher donor ECD (P = 0.042) were the primary factors for a lower ECD loss rate at 12 months after DMEK.

CONCLUSION

A relatively larger graft size compared to the host cornea and more donor ECD might help endothelial survival in patients with BK. Moreover, for such patients, the surgeon should attempt to use a relatively larger graft size when performing DMEK, particularly in Asian eyes.

Guiding flying-spot laser transepithelial phototherapeutic keratectomy with optical coherence tomography

PURPOSE

To analyze transepithelial phototherapeutic keratectomy (PTK) results using optical coherence tomography (OCT) and develop a model to guide the laser dioptric and depth settings.

SETTING

Casey Eye Institute, Portland, Oregon, USA.

DESIGN

Prospective nonrandomized case series.

METHODS

Patients with superficial corneal opacities and irregularities had transepithelial PTK with a flying-spot excimer laser by combining wide-zone myopic and hyperopic astigmatic ablations. Optical coherence tomography was used to calculate corneal epithelial lenticular masking effects, guide refractive laser settings, and measure opacity removal. The laser ablation efficiency and the refractive outcome were investigated using multivariate linear regression models.

RESULTS

Twenty-six eyes of 20 patients received PTK to remove opacities and irregular astigmatism due to scar, dystrophy, radial keratotomy, or previous corneal surgeries. The uncorrected distance visual acuity and corrected distance visual acuity were significantly improved (P < .01) by 3.7 Snellen lines and 2.0 Snellen lines, respectively, to a mean of 20/41.2 and 20/22.0, respectively. Achieved laser ablation depths were 31.3% (myopic ablation) and 63.0% (hyperopic ablation) deeper than the manufacturer's nomogram. The spherical equivalent of the corneal epithelial lenticular masking effect was 0.73 diopter ± 0.61 (SD). The refractive outcome highly correlated to the laser settings and epithelial lenticular masking effect (Pearson R = 0.96, P < .01). The ablation rate of granular dystrophy opacities appeared to be slower. Smoothing ablation under masking fluid was needed to prevent focal steep islands in these cases.

CONCLUSIONS

The OCT-measured ablation depth efficiency could guide opacity removal. The corneal epithelial lenticular masking effect could refine the spherical refractive nomogram to achieve a better refractive outcome after transepithelial ablation.

Clinical Evaluation of the NS Endo-Inserter, a Novel Donor Inserter for Descemet's Stripping Automated Endothelial Keratoplasty

Purpose

This study investigated the clinical outcomes achieved with a newly developed donor inserter (NS Endo-Inserter [NSI], HOYA Co., Ltd., Tokyo, Japan) for Descemet's stripping automated endothelial keratoplasty (DSAEK) in Japanese eyes with bullous keratopathy secondary to argon laser iridotomy (BK-ALI). The NSI device utilizes pressure flow to push the DSAEK donor tissue into the anterior chamber.

Methods

Six eyes of 6 patients (1 male, 5 females; mean age, 78.5 years) with BK-ALI were enrolled. Donor tissue was pushed into the anterior chamber using the NSI. Intraoperative complications, graft dislocation, and iatrogenic primary graft failure were recorded for all eyes. Six-month postoperative central donor endothelial cell densities (ECD) were measured prospectively and compared with preoperative values, along with 6-month best corrected visual acuity (BCVA).

Results

In all cases, donor loading onto the NSI spatula and donor insertion into the anterior chamber using the NSI was smooth and successful; no intraoperative complications were noted. There were no cases of graft dislocation or IPGF. Postoperative ECD was 2,187.2 cells/mm² (mean loss, 14.8%) and mean BCVA increased from 0.27 decimal to 0.8 at 6 months.

Conclusion

In this small preliminary case series, clinical outcomes for patients with BK-ALI undergoing DSAEK using the NSI were comparable or better than those achieved with conventional DSAEK insertion techniques.

Changing indications and surgical techniques for keratoplasty during a 16-year period (2003-2018) at a tertiary referral hospital in Japan

Purpose

To present the changing indications and surgical techniques for keratoplasty during a 16-year period (2003–2018) at a tertiary referral hospital in Japan.

Methods

Consecutive keratoplasty cases at Kanazawa University Hospital from January 2003 to December 2018 were retrospectively reviewed. Keratoplasty procedures included penetrating keratoplasty (PK), deep anterior lamellar keratoplasty (DALK), anterior lamellar keratoplasty (ALK), Descemet’s stripping automated endothelial keratoplasty (DSAEK), and Descemet’s membrane endothelial keratoplasty (DMEK). Annual numbers and types of keratoplasty as well as underlying diseases for PK and total keratoplasty procedures were recorded, and annual trends were statistically analyzed using Cochran–Armitage test for trend.

Results

A total of 801 keratoplasty procedures (PK, 319 cases; DALK, 57 cases; ALK, 9 cases; DSAEK, 371 cases; and DMEK 45 cases; mean age, 66.9±16.3 years) were performed for 595 patients (302 males [329 eyes, 419 cases], 293 females [345 eyes, 382 cases]) during the 16-year period. The proportion of PK procedures decreased significantly in the beginning and showed a slightly increasing trend after a plateau around 2015. DSAEK was increasing after 2006 and reached a plateau around 2012. Among 10 underlying diseases for total keratoplasty, corneal opacity and dermoid were decreasing linearly. Failed PK and failed DSAEK were increasing linearly in the beginning and reached a plateau followed by a decreasing trend. In terms of the underlying disease for PK, bullous keratopathy was decreasing in the beginning and reached a plateau around 2015. A total of 19 PK procedures were performed on cases with recalcitrant bullous kerstopathy (BK) after 2010.

Conclusion

The distribution of keratoplasty procedures and underlying diseases changed significantly over 16 years at a tertiary referral hospital in Japan. PK procedure was significantly decreased and DSAEK procedure was significantly increased. PK for BK decreased significantly; however, PK remains a viable option for other recalcitrant corneal diseases.

Surgery-induced iris abnormalities after Descemet membrane endothelial keratoplasty and their impact on postoperative clinical outcomes

Purpose: This study aimed to elucidate the frequency of surgery-induced iris abnormalities after Descemet membrane endothelial keratoplasty (DMEK) and their impact on postoperative clinical outcomes.

Methods: In this retrospective study, medical records of 32 eyes from 28 consecutive patients (mean age, 65.7±13.4 years; 14 men, 18 women) who underwent DMEK (or triple DMEK) were reviewed. In all patients, inferior peripheral iridectomy was created leaving full intracameral air tamponade at the end of surgery. Sulfur hexafluoride gas was not used in any cases. Surgery-induced iris abnormalities such as pupillary shape changes and iris depigmentation were evaluated by 3 masked observers. Pre-existing abnormalities were excluded. Eyes were divided into two groups based on the presence of surgery-induced iris changes: Group A (with iris abnormalities) and Group B (without). Impacts on postoperative clinical outcomes such as vision and endothelial cell density were analyzed.

Results: Surgery-induced iris abnormalities were seen in 15 eyes (Group A, 9 with pupillary shape change and 6 with iris depigmentation; 46.9%), and 17 eyes showed no abnormalities (Group B, 53.1%). No significant differences were detected between groups in age, sex, indication, simultaneous cataract surgery, pre- and 6-month postoperative vision, donor age, donor endothelial cell density, and 6- and 12-month postoperative endothelial cell density.

Conclusions: Surgery-induced iris abnormalities were noted in almost half of the eyes after DMEK (46.9%) in this study. However, there was no association between visual outcomes or postoperative endothelial cell density and the iris changes.

In vivo histology and p.L132V mutation in KRT12 gene in Japanese patients with Meesmann corneal dystrophy

PURPOSE

To report genetic mutational analysis and in vivo histology of Meesmann corneal dystrophy.

STUDY DESIGN

Prospective, case control study.

METHODS

Six patients from three independent families with clinically diagnosed Meesmann corneal dystrophy were enrolled in this study. Slit-lamp biomicroscopy with fluorescein vital staining, anterior segment optical coherence tomography (AS-OCT), and in vivo laser confocal microscopy (IVCM) were performed on selected patients. Mutational screening for the keratin genes KRT3 and KRT12 was performed in all six patients and selected unaffected family members.

RESULTS

Slit-lamp biomicroscopy revealed numerous intraepithelial microcysts in all affected individuals. AS-OCT revealed hyperreflectivity and high corneal epithelial layer thickness (mean, 64.8μm) in all individuals tested (3/3). By using IVCM, multiple epithelial microcysts and hyperreflective materials (6/6), subepithelial nerve abnormalities (6/6), tiny punctate hyperreflective material (6/6), and needle-like hyperreflective materials (4/6) were observed in the corneal stromal layer. A heterozygous genetic mutation in the KRT12 gene (c.394 C>G, p.L132V) was identified in all six patients. No pathological mutation was observed in the KRT3 gene.

CONCLUSION

We identified a heterozygous genetic mutation (c.394 C>G, p.L132V) in the KRT12 gene in six Japanese patients with inherited Meesmann corneal dystrophy. This is the first study to confirm this genetic mutation in Japanese Meesmann corneal dystrophy patients. This mutation has been independently reported in an American Meesmann corneal dystrophy patient, confirming its pathogenicity. AS-OCT and IVCM proved to be useful tools for observing corneal epithelial layer pathology in this dystrophy. Furthermore, IVCM reveals corneal stromal layer pathological changes not previously reported in this dystrophy.

Development of a Donor Tissue Holding Technique for Descemet's Membrane Endothelial Keratoplasty Using a 25-Gauge Graft Manipulator

Purpose

To report a modified surgical technique called the “donor tissue holding technique for Descemet's membrane endothelial keratoplasty (DMEK)” using a newly developed 25-gauge graft manipulator.

Methods

Six consecutive patients exhibiting endothelial dysfunction were enrolled and treated by DMEK. In brief, after insertion of a DMEK donor into the anterior chamber, the edge of the roll was grasped using a graft manipulator and this grasp was maintained throughout the centering and opening of the roll (holding technique). The following parameters were evaluated in comparison to the previous 10 consecutive DMEK cases in which the no touch technique was used: time of graft unfolding, incidence of intra-/postoperative complications, and best spectacle-corrected visual acuity (BCVA) and endothelial cell density (ECD) 6 months after the procedure.

Results

In both technique groups, neither intra- nor postoperative complications were noted in any case. No differences were observed between the two groups in postoperative BCVA (p = 0.88). Also, no differences were observed between the two groups in postoperative ECD (holding technique group: 2,108.3 cells/mm², no touch technique group: 1,491.7 cells/mm²) (p = 0.08) Most notably, the time of graft unfolding prior to filling with air was significantly reduced in the holding technique group (305.5 s) compared to that of the no touch technique group (1,310.0 s; p = 0.01).

Conclusions

This donor tissue holding technique enabled rapid and safe DMEK in a reproducible manner, even in Asian eyes with shallow anterior chambers with high vitreous pressure.

A 10-year review of underlying diseases for endothelial keratoplasty (DSAEK/DMEK) in a tertiary referral hospital in Japan

Purpose

To report a 10-year review of endothelial keratoplasty (EK) procedures, Descemet's stripping automated endothelial keratoplasty (DSAEK) and Descemet's membrane endothelial keratoplasty (DMEK), and underlying diseases at a tertiary referral hospital in Japan.

Study design

A single-center, retrospective case series.

Methods

We retrospectively reviewed all medical records of bullous keratopathy (BK) surgically treated by EK (DSAEK/DMEK) at Kanazawa University Hospital from January 2007 to December 2016. Changes or modifications to the annual number of EK procedures and underlying diseases were analyzed.

Results

During this period, 320 EK procedures (DSAEK: 288 cases, DMEK: 32 cases) were performed on 250 patients. Total annual EKs gradually increased from 19 to 45 cases between 2007 and 2016. The annual number of DSAEKs was stable, although the proportion of DSAEKs to other procedures decreased significantly as re-DSAEKs and DMEKs increased. BK after argon laser iridotomy (ALI) was the leading cause in 2007, followed by Fuchs' endothelial dystrophy (FED) and failed penetrating keratoplasty. In 2016, BK after trabeculectomy (TLE) was most prevalent, followed by failed DSAEK, failed penetrating keratoplasty, and pseudophakic BK. The decreased ALI and FED, and increased BK after TLE and failed DSAEK were statistically significant.

Conclusion

The distribution of EK procedures (DSAEK/DMEK) and underlying diseases changed over 10 years at a tertiary referral hospital in Japan. The proportion of re-DSAEK and DMEK increased among all EK procedures. Most significantly, among the underlying diseases, decreased ALI and FED and increased TLE and failed DSAEK were observed. Extended multicenter analysis may further elucidate the changes in EK procedures and the causes of BK in Japan.

Association of fluorescein anterior corneal mosaic and corneal K-structures by in vivo laser confocal microscopy in patients with keratoconus

Objective

To report the in vivo laser confocal microscopy findings of corneas with keratoconus, with special attention to abnormality of Bowman’s layer and sub-Bowman’s fibrous structures (Kobayashi-structures [K-structures]).

Methods

Sixteen keratoconic eyes in 8 consecutive patients with keratoconus (4 males, 4 females, mean age, 41.1 years) were included in this study. Slit-lamp biomicroscopic photos were taken with or without fluorescein staining. The existence of anterior corneal mosaic (ACM) after eyelid rubbing under fluorescein staining was documented. In vivo laser confocal microscopic examinations were performed for all patients in both the central cone and the peripheral cornea to examine the existence of K-structures.

Results

According to the Amsler–Krumeich scale, the eyes were graded as follows: stage 1 (n=3), stage 2 (n=1), stage 3 (n=1), and stage 4 (n=11). ACM was observed in 7 eyes (61.1%) in the cone area and 16 eyes (100%) in the peripheral cornea among all keratoconic eyes enrolled in this study. In addition, K-structures were observed in the 7 eyes (61.1%) and 16 eyes (100%) in the peripheral cornea among all keratoconic eyes. The presence of the K-structures was completely matched (100%) with the presence of ACM in both the central cone and the peripheral cornea. In 11 eyes with stage 4 keratoconus, ACM and K-structure was absent in 9 eyes (81.8%) in the cone area. On the contrary, in 5 eyes with mild-to-moderate keratoconus (grade 1 to 3), ACM and K-structure was present in all eyes (100%) in the cone area. The absent ratio of ACM and K-structures in the cone area was significantly higher in stage 4 severe keratoconus compared to mild-to-moderate keratoconus (grade 1 to 3) (Fisher, P=0.005).

Conclusion

The existence of ACM and K-structures in both the central cone and the peripheral cornea showed perfect accord in patients with keratoconus, indicating a strong association of ACM and K-structures in patients with keratoconus. With the progress of the keratoconus, it seemed that ACM and K-structure progressively disappeared, suggesting Bowman’s layer abnormalities due to keratoconus. Further study in larger groups of patients with keratoconus is required to fully understand the significance of ACM/K-structures in keratoconic eyes and their association with Bowman’s layer.

Visualization of precut DSAEK and pre-stripped DMEK donor corneas by intraoperative optical coherence tomography using the RESCAN 700

BACKGROUND

To report the feasibility of intraoperative spectral domain optical coherence tomography (OCT) using the RESCAN 700 for the visualization and evaluation of precut Descemet's stripping automated endothelial keratoplasty (DSAEK) and prestripped Descemet's membrane endothelial keratoplasty (DMEK) donor tissue.

METHODS

Precut DSAEK (n = 11), prestripped DMEK (n = 4) preserved in a viewing chamber were examined by intraoperative OCT. Wholly intact donor corneas for penetrating keratoplasty (PK) (n = 8) were also examined as controls. The obtained images were analyzed qualitatively for characteristics of each type of donor.

RESULTS

For each type of donor, characteristic images were consistently obtained by intraoperative OCT in both the front and back views through the viewing chamber. In wholly intact donors for PK, appearance of normal corneal curvature and stromal texture with high reflectivity of epithelium and endothelium cell layers were clearly visualized. In precut DSAEK donors, precut lines were characteristically visualized in addition to the intact donor cornea images. In prestripped DMEK donors, identical OCT images to the intact donor cornea were noted when observed from the anterior surface. However, peripheral partial detachments of Descemet's membrane were characteristically observed in all prestripped DMEK donors when viewed from the back of the viewing chamber.

CONCLUSION

Rapid visualization and rough evaluation of donor tissues for PK, precut DSAEK and prestripped DMEK donor corneas by intraoperative OCT was consistently possible through the viewing chamber. Therefore, this device may be used as an alternative of AS-OCT when the eyebank does not have their own AS-OCT. Although the peripheral detachment in DMEK donors are quite common and clinically non-problematic in DMEK donor quality and subsequent DMEK surgeries, it may be useful to distinguish between wholly intact PK donors and prestripped DMEK donors, enabling to prevent mix-ups of donors, especially when several different types of keratoplasties are scheduled in a same day in one operating theater.

Mapping of dendritic lesions in patients with herpes simplex keratitis using in vivo confocal microscopy

Purpose

To produce a two-dimensional reconstruction map of dendritic lesions in patients with herpes simplex keratitis (HSK) using in vivo confocal microscopy.

Methods

Four eyes of four patients (mean 65.8 years) with HSK presenting with a dendritic lesion were enrolled. Slit-lamp biomicroscopy and in vivo laser confocal microscopy were performed. Acquired confocal images at the level of the epithelium were arranged and mapped into subconfluent montages. Changes in the shape and degree of light reflection of abnormal cells and deposits around dendritic lesions as well as other corneal layers were qualitatively evaluated.

Results

Mapping of dendritic lesion was successful in all cases, and the subconfluent montages clearly showed the larger image of dendritic lesion. In all cases, the dendritic lesion consisted of hyperreflective irregular epithelial cells, and was surrounded by distorted and elongated epithelial cells. In three cases, hyperreflective deposits were noted at the midline of the lesion. The corneal stroma showed a hyperreflective honeycomb pattern. In two cases, inflammatory cells were observed at the level of endothelial cell layer.

Conclusion

Mapping of dendritic lesions in patients with HSK was successful in all patients using in vivo confocal microscopy. Cellular level observation of dendritic lesion at a relatively larger magnification may help understand the in vivo morphological change of HSK. Further study in more patients with HSK and nonherpetic dendritic lesion is needed to utilize confocal microscopy images in differential diagnosis and follow-up of the epithelial lesions with dendrite.

Case series and techniques of Descemet's Stripping Automated Endothelial Keratoplasty for severe bullous keratopathy after birth injury

BACKGROUND

To evaluate clinical outcomes of Descemet's Stripping Automated Endothelial Keratoplasty (DSAEK) for severe bullous keratopathy that develop as a late complication of endothelial injury to the baby during forceps delivery at birth.

CASE PRESENTATIONS

Four eyes (four patients; mean age, 51.5 years) with severe bullous keratopathy as a late complication of forceps delivery at birth were enrolled. All patients had amblyopia from childhood due to cloudy cornea. Nontheless, DSAEK was indicated in these patients for the irritation and severe light sensation caused by apparent bullous change of the injured cornea. All patients underwent DSAEK and two patients had simultaneous cataract surgery. Intraoperative and postoperative complications were recorded. Postoperative donor endothelial-cell densities (ECDs) were measured prospectively at six and 12 months and compared with preoperative values. Best corrected visual acuity (BCVA) was measured at 6 and 12 months postoperatively. All cases required corneal epithelial removal; two cases with simultaneous cataract surgeries required lens anterior capsule staining by trypan blue and illumination of the cornea for visualization. There were no cases of graft dislocation or primary graft failure. Mean BCVA improved from 0.06 to 0.15 at 6 months and to 0.38 at 12 months. Postoperative ECD was 2270 cells/mm(2) (mean loss, 24.4 %) at 6 months and 2130 (mean loss, 29.1 %) at 12 months. Postoperative intraocular pressure elevation was observed in two cases, and a rejection episode occurred in one case at 4 months postoperatively.

CONCLUSIONS

In this case series, the clinical outcome of DSAEK for severe bullous keratopathy after forceps delivery was fair with rapid corneal clearance, which was comparable to uncomplicated cases. Cataract and DSAEK surgery was safely performed using techniques including epithelial removal, lens anterior capsule staining and illuminating the cornea, which enabled better visualization of the anterior chamber.

The use of endoillumination probe-assisted Descemet membrane endothelial keratoplasty for bullous keratopathy secondary to argon laser iridotomy

Purpose

To report the first case of Descemet membrane endothelial keratoplasty (DMEK) for bullous keratopathy (BK) secondary to argon laser iridotomy (ALI).

Patient

A 71-year-old woman presented with decreased visual acuity in her right eye due to BK secondary to ALI that was performed 10 years prior.

Results

Phacosurgery was performed first, followed by successful DMEK 4 months later. A DMEK shooter was used for donor insertion, which allowed for a stable anterior chamber during donor insertion, even when the anterior chamber was quite shallow. Also, removal of edematous epithelial cells and endoillumination probe-assisted DMEK was quite useful to visualize DMEK graft on the background of the dark brown iris seen in Asian eyes. The patient’s best corrected visual acuity rapidly increased from 20/200 to 25/20 after 1 month, with complete resolution of corneal edema.

Conclusion

We reported the first successful DMEK case for BK secondary to ALI. The use of a DMEK shooter for donor insertion and endoillumination assistance to visualize the DMEK graft was a useful technique for BK secondary to ALI.

Surgical therapies for corneal perforations: 10 years of cases in a tertiary referral hospital

Purpose

To report surgical therapies for corneal perforations in a tertiary referral hospital.

Methods

Thirty-one eyes of 31 patients (aged 62.4±18.3 years) with surgically treated corneal perforations from January 2002 to July 2013 were included in this study. Demographic data such as cause of corneal perforation, surgical procedures, and visual outcomes were retrospectively analyzed.

Results

The causes of corneal perforation (n=31) were divided into infectious (n=8, 26%) and noninfectious (n=23, 74%) categories. Infectious causes included fungal ulcer, herpetic stromal necrotizing keratitis, and bacterial ulcer. The causes of noninfectious keratopathy included corneal melting after removal of a metal foreign body, severe dry eye, lagophthalmos, canaliculitis, the oral anticancer drug S-1, keratoconus, rheumatoid arthritis, neurotrophic ulcer, atopic keratoconjunctivitis, and unknown causes. Initial surgical procedures included central large corneal graft (n=17), small corneal graft (n=7), and amniotic membrane transplantation (n=7). In two cases the perforation could not be sealed during the first surgical treatment and required subsequent procedures. All infectious keratitis required central large penetrating keratoplasty to obtain anatomical cure. In contrast, several surgical options were used for the treatment of noninfectious keratitis. After surgical treatment, anatomical cure was obtained in all cases. Mean postoperative best corrected visual acuity was better at 6 months (logMAR 1.3) than preoperatively (logMAR 1.8).

Conclusion

Surgical therapies for corneal perforations in our hospital included central large lamellar/penetrating keratoplasty, small peripheral patch graft, and amniotic membrane transplantation. All treatments were effective. Corneal perforation due to the oral anticancer drug S-1 is newly reported.

Endothelial keratoplasty with infant donor tissue

Here we report a case of endothelial keratoplasty with infant donor tissue obtained after brain death. A 52-year-old man with endothelial dysfunction of unknown cause in the right eye underwent non-Descemet stripping automated endothelial keratoplasty (nDSAEK) with tissue from an infant donor (2 years). Intraoperative and postoperative complications were recorded. Best corrected visual acuity and donor central endothelial cell density were recorded preoperatively and postoperatively. Infant donor tissue preparation with a microkeratome set at 300 μm was successful; the donor tissue was extremely elastic and soft compared with adult tissue. The central endothelial cell density of the infant donor tissue was as high as 4,291 cells/mm². No complications were observed during donor tissue (8.0 mm in diameter) insertion with the double-glide technique (Busin glide with intraocular lens sheet glide) or any of the other procedures. Best corrected visual acuity improved from 1.7 logMAR (logarithm of the minimum angle of resolution; 0.02 decimal visual acuity) preoperatively to 0.2 logMAR (0.6) after 6 months and 0.1 logMAR (0.8) after 1 year. The central endothelial cell density after 6 months was 4,098 cells/mm² (representing a 4.5% cell loss from preoperative donor cell measurements), and the central endothelial cell density after 1 year was 4,032 cells/mm² (6.0% decrease). Infant donor tissue may be preferably used for DSAEK/nDASEK, since it may not be suitable for penetrating keratoplasty or Descemet membrane endothelial keratoplasty.

In vivo laser confocal microscopy findings of a cornea with osteogenesis imperfecta

Objective

To report the in vivo laser confocal microscopy findings of a cornea with osteogenesis imperfecta (OI) with special attention to the abnormality of Bowman’s layer and sub-Bowman’s fibrous structures (K-structures).

Patients and methods

Two patients (67-year-old male and his 26-year-old son) with OI type I were included in this study. Slit lamp biomicroscopic and in vivo laser confocal microscopic examinations were performed for both patients. Central corneal thickness and central endothelial cell density were also measured.

Results

Although the corneas looked clear with normal endothelial density for both eyes in both patients, they were quite thin (386 μm oculus dexter (OD) (the right eye) and 384 μm oculus sinister (OS) (the left eye) in the father and 430 μm OD and 425 μm OS in the son). In both patients, slit lamp biomicroscopic and in vivo laser confocal microscopic examination showed similar results. Anterior corneal mosaics produced by rubbing the eyelid under fluorescein were completely absent in both eyes. In vivo laser confocal microscopy revealed an absent or atrophic Bowman’s layer; a trace of a presumed Bowman’s layer and/or basement membrane was barely visible with high intensity. Additionally, K-structures were completely absent in both eyes.

Conclusion

The absence of K-structures and fluorescein anterior corneal mosaics strongly suggested an abnormality of Bowman’s layer in these OI patients.

Descemet's stripping and non-Descemet's stripping automated endothelial keratoplasty for microcornea using 6.0 mm donor grafts

Background

The purpose of this paper is to report our experience of Descemet’s stripping and non-Descemet’s stripping automated endothelial keratoplasty (DSAEK/nDSAEK) for microcorneas using 6.0 mm donor grafts.

Methods

Three eyes of two patients (a 56-year-old woman and a 59-year-old woman) with microcornea and suffering from bullous keratopathy were treated with either DSAEK or nDSAEK. A small donor graft (6.0 mm) was inserted into the anterior chamber using a double glide (Busin glide and intraocular lens sheet glide) donor insertion technique. Both patients were followed for at least 12 months. Clinical outcomes, including intraoperative and postoperative complications, visual acuity, and endothelial cell density were evaluated.

Results

In all three cases (100%), no intraoperative complications were noted. In one case with a flat keratometry value (32.13 D), a partial donor detachment was noted one day postoperatively, but it was reattached by rebubbling. In another case, rejection was noted 8 months postoperatively, but treatment with systemic corticosteroids was successful. A clear cornea remained in all three cases (100%), with best-corrected visual acuity greater than 20/100 (mean 20/50) at 12 months. Mean postoperative endothelial cell counts were 2,603 ± 18 cells/mm² at 6 months (7.4% decrease from preoperative donor cell counts) and 1,799 ± 556 cells/mm² at 12 months (36.5% decrease).

Conclusion

We report for the first time the successful use of a small donor graft (6.0 mm) for DSAEK/nDSAEK in cases of microcornea. Additional stud ies using a large number of patients are required to evaluate fully the potential advantages and drawbacks of small diameter donor grafts for microcornea.

A Case of Bilateral Descemet's Membrane and Subepithelial Opacity: In vivo Laser Confocal Microscopic Study

Purpose

To report the in vivo laser confocal microscopy findings from a patient with Descemet's membrane and subepithelial opacity OU.

Case Report

A healthy 41-year-old male with Descemet's membrane and subepithelial opacity OU was studied. Routine ophthalmic examination, standard slit-lamp biomicroscopy, and in vivo laser confocal microscopic analysis of the entire corneal layer were performed. Slit-lamp biomicroscopy revealed subepithelial opacity in the mid-peripheral to peripheral cornea and numerous opacities located at the level of Descemet's membrane. It was difficult to distinguish the precise histological location of the opacity. In vivo laser confocal microscopy showed numerous hyperreflective particles in the subepithelium to superficial stroma and hyperreflectivity of Descemet's membrane. No abnormalities could be detected in the epithelial cell layer, midstromal layer, deep stromal layer, or endothelial cell layer.

Conclusion

Although the origin of the corneal opacities was unclear, in vivo laser confocal microscopy was useful for observing microstructural abnormalities in a case of Descemet's membrane and subepithelial opacity.

Clinical features of single and repeated globe rupture after penetrating keratoplasty

BACKGROUND

In this paper, we report our experience of the clinical features of single and repeated globe rupture after penetrating keratoplasty.

METHODS

We undertook a retrospective analysis of single and repeated globe ruptures following keratoplasty in eight eyes from seven consecutive patients referred to Kanazawa University Hospital over a 10-year period from January 2002 to March 2012. We analyzed their ophthalmic and demographic data, including age at time of globe rupture, incidence, time interval between keratoplasty and globe rupture, cause of rupture, complicated ocular damage, and visual outcome after surgical repair.

RESULTS

Five patients (71.4%) experienced a single globe rupture and two patients (28.6%) experienced repeated globe ruptures. Patient age at the time of globe rupture was 75.4 ± 6.8 (range 67-83) years. Four of the patients were men and three were women. During the 10-year study period, the incidence of globe rupture following penetrating keratoplasty was 2.8%. The time interval between penetrating keratoplasty and globe rupture was 101 ± 92 months (range 7 months to 23 years). The most common cause of globe rupture in older patients was a fall (n = 5, 79.8 ± 3.7 years, all older than 67 years). Final best-corrected visual acuity was >20/200 in three eyes (37.5%). In all except one eye, globe rupture involved the graft-host junction; in the remaining eye, the rupture occurred after disruption of the extracapsular cataract extraction wound by blunt trauma.

CONCLUSION

Preventative measures should be taken to avoid single and repeated ocular trauma following penetrating keratoplasty.

Identification of cytomegalovirus and human herpesvirus-6 DNA in a patient with corneal endotheliitis

PURPOSE

To report the case of a patient with unilateral corneal endotheliitis in which both cytomegalovirus (CMV) and human herpesvirus-6 (HHV6) DNA was identified in the aqueous humor.

CASE

A 67-year-old man with corneal endotheliitis OD was referred to us for decreased visual acuity. Local corneal stromal edema, pigmented keratic precipitates, a coin-shaped lesion and minimal anterior chamber reaction were observed by slit-lamp biomicroscopy. Cells with owl's eye appearance in the endothelial cell layer were observed by in vivo laser confocal microscopy. The patient had rheumatoid arthritis, which was treated by oral prednisolone and intravenous abatacept. Polymerase chain reaction analysis of aqueous humor samples detected both CMV and HHV6 DNA, but not other HHVs. Treatment with topical ganciclovir and systemic valganciclovir resulted in a clear cornea.

CONCLUSIONS

A patient with corneal endotheliitis had both CMV and HHV6 DNA identified in the aqueous humor. Although both viruses were identified in this case, clinical manifestations resembled CMV corneal endotheliitis, and it was unclear whether HHV6 could affect the clinical course. Systemic abatacept and corticosteroid therapy might play a positive role in cases with both CMV and HHV6 DNA in this corneal endotheliitis.

Subfoveal choroidal thickness change following segmental scleral buckling for rhegmatogenous retinal detachment

PURPOSE

To report the morphologic changes of the subfoveal choroidal thickness using spectral-domain optical coherence tomography following segmental scleral buckling.

DESIGN

Retrospective, observational case series.

METHODS

The study included 21 eyes of 20 patients who underwent segmental scleral buckling for the treatment of rhegmatogenous retinal detachment. All patients underwent the measurements of the subfoveal choroidal thickness preoperatively and 1 week, 1 month, and 3 months after the surgery. The changes in choroidal thickness, 4 mm from the fovea, before and 1 week after surgery were analyzed in the buckled and unbuckled side.

RESULTS

The preoperative mean subfoveal choroidal thickness of operated eyes was 239.2 ± 91.0 μm. The postoperative mean subfoveal choroidal thicknesses of operated eyes at 1 week, 1 month, and 3 months were 267.6 ± 96.8 μm, 250.6 ± 95.8 μm, and 239.4 ± 95.6 μm, respectively. There were significant differences between preoperative subfoveal choroidal thickness and 1-week-postoperative and 1-month-postoperative subfoveal choroidal thicknesses (P < .01, P = .03, ANOVA), and there was no significant difference between subfoveal choroidal thicknesses preoperatively and 3 months postoperatively (P > .99, ANOVA). The changes in choroidal thickness of the buckled and unbuckled side preoperatively and 1 week postoperatively were not significantly different (n = 8, P = .589, 2-way ANOVA).

CONCLUSION

The subfoveal choroidal thickness may change temporarily following segmental scleral buckling surgery. This may be the result of reversible subclinical microcirculatory dysfunction of the choroid.

Ex vivo laser confocal microscopy findings of cultured Acanthamoeba trophozoites

Purpose

The purpose of the current study was to investigate ex vivo laser confocal microscopic findings of cultured Acanthamoeba trophozoites obtained from Acanthamoeba keratitis patients.

Methods

Eight cultured samples of Acanthamoeba trophozoites from eight eyes of seven patients (mean age, 26.9 years; age range, 18–52 years) were used. Seven samples were from corneal scrapings of Acanthamoeba keratitis patients and one sample was from the solution in a soft contact lens case. Ex vivo laser confocal microscopy was performed to qualitatively evaluate the shape and degree of light reflection of the living Acanthamoeba trophozoites.

Results

Ex vivo laser confocal microscopy demonstrated highly reflective, high-contrast Acanthamoeba trophozoites with no walls (mean size, 25.4 μm; range, 17.1–58.5 μm). The shapes of the trophozoites were highly pleomorphic, and some showed characteristic acanthopodia by laser confocal microscopy.

Conclusion

Ex vivo laser confocal microscopy was effective in demonstrating cultured Acanthamoeba trophozoites of various shapes and sizes. The observations of the current study may be helpful when similar structures are identified under in vivo conditions.

Bowman's layer encystment in cases of persistent Acanthamoeba keratitis

BACKGROUND

The purpose of this study was to report Acanthamoeba encystment in Bowman's layer in Japanese cases of persistent Acanthamoeba keratitis (AK).

METHODS

Laser confocal microscopic images of the cornea were obtained in vivo from 18 consecutive eyes from 17 confirmed AK patients. Retrospectively, 14 cases treated over 4 months were categorized as a nonpersistent group and three cases that required prolonged therapy for more than 6 months were categorized as a persistent group. Clinical outcomes based on final best-corrected visual acuity were retrospectively analyzed, and selected confocal images were evaluated qualitatively for abnormal findings.

RESULTS

The final best-corrected visual acuity was significantly lower (P < 0.01) for patients in the persistent group compared with that in the nonpersistent group. At the initial visit, in vivo confocal microscopy demonstrated Acanthamoeba cysts exclusively in the epithelial layer in both the nonpersistent group (80%) and the persistent group (100%). At a subsequent follow-up visit, numerous Acanthamoeba cysts were observed in the epithelial cell layer and in Bowman's layer in all patients with persistent AK, but Acanthamoeba cysts were undetectable in all cases with nonpersistent AK tested.

CONCLUSION

Invasion of cysts into Bowman's layer was characteristically observed in patients with persistence of AK. This finding suggests that invasion of Acanthamoeba cysts into Bowman's layer may be a useful predictor for a persistent clinical course.

A sliding technique to load thin endothelial donor lamella onto Busin glide for Descemet-stripping automated endothelial keratoplasty

We describe a modified technique for loading donor corneal endothelial lamella onto a Busin glide^® without causing wrinkles, as part of the procedure of Descemet-stripping automated endothelial keratoplasty. Briefly, after punching out a composite of the donor-endothelial lamella and a microkeratome-dissected cap, several drops of dispersive ophthalmic viscosurgical device are placed onto the endothelial surface. The Busin glide surface is then wetted with several drops of balanced salt solution. After the composite is transferred onto the Busin glide, hydrodissection of the potential space between the donor-endothelial lamella and the microkeratome-dissected cap is carefully performed to enable smooth detachment of these two lamellae. Whereas simply dragging the donor-endothelial lamella directly onto the glide can cause wrinkling or folding of the donor lamella, this technique enables smooth detachment of the composite without wrinkle or fold formation, and results in less endothelial cell damage.

In vivo laser confocal microscopy findings in patients with map-dot-fingerprint (epithelial basement membrane) dystrophy

Background:

The purpose of this study was to investigate pathological changes of the corneal cell layer in patients with map-dot-fingerprint (epithelial basement membrane) dystrophy by in vivo laser corneal confocal microscopy.

Methods:

Two patients were evaluated using a cornea-specific in vivo laser scanning confocal microscope (Heidelberg Retina Tomograph 2 Rostock Cornea Module, HRT 2-RCM). The affected corneal areas of both patients were examined. Image analysis was performed to identify corneal epithelial and stromal deposits correlated with this dystrophy.

Results:

Variously shaped (linear, multilaminar, curvilinear, ring-shape, geographic) highly reflective materials were observed in the “map” area, mainly in the basal epithelial cell layer. In “fingerprint” lesions, multiple linear and curvilinear hyporeflective lines were observed. Additionally, in the affected corneas, infiltration of possible Langerhans cells and other inflammatory cells was observed as highly reflective Langerhans cell-like or dot images. Finally, needle-shaped materials were observed in one patient.

Conclusion:

HRT 2-RCM laser confocal microscopy is capable of identifying corneal microstructural changes related to map-dot-fingerprint corneal dystrophy in vivo. The technique may be useful in elucidating the pathogenesis and natural course of map-dot-fingerprint corneal dystrophy and other similar basement membrane abnormalities.

No-Touch Technique and a New Donor Adjuster for Descemet's Stripping Automated Endothelial Keratoplasty

Purpose

One difficulty with Descemet's stripping automated endothelial keratoplasty (DSAEK) is air management during surgery and donor endothelial lamella centering. We evaluated the no-touch technique for donor centering and the use of a newly developed DSAEK donor adjuster.

Methods

We evaluated the records of 12 consecutive patients (mean age 75.3 years) with bullous keratopathy who had undergone DSAEK. In all cases, the no-touch technique was attempted first. When the no-touch technique failed, a DSAEK donor adjuster with a 30-gauge cannula resembling a curved reverse Sinskey hook was used for donor centering. The adjuster allows air injection during donor centering.

Results

The no-touch technique using simple corneal surface massage to center the graft was successful in 4 cases (33.3%), while 4 cases required ocular tilting (33.3%) in addition to corneal surface massage. The no-touch technique was ineffective in 4 cases (33.3%), but the donor adjuster was used successfully and easily for these patients. Comparing the endothelial cell loss rate between the no-touch technique group and the donor adjuster group, there was no significant difference at 6 months.

Conclusions

The no-touch technique was useful for better control of DSAEK donor centering in most cases. When the no-touch technique was ineffective, the DSAEK donor adjuster was uniformly successful.

Management of a small paracentral corneal perforation using iatrogenic iris incarceration and tissue adhesive

BACKGROUND

Surgical intervention for corneal perforation is indicated when the anterior chamber does not reform within a short period of time. Herein, we report the successful management of a small paracentral corneal perforation using autologous iris incarceration and tissue adhesive.

CASE

A 41-year-old man developed a small paracentral corneal perforation (0.5 mm in size) in the right eye, while the treating physician attempted to remove the residual rust ring after removal of a piece of metallic foreign body.

OBSERVATIONS

The eye was initially managed with a bandage soft contact lens to ameliorate the aqueous leakage; however, without success. Iatrogenic iris incarceration of the wound was first induced, followed by application of cyanoacrylate tissue adhesive to the perforated site. As a result, the anterior chamber was immediately reformed and maintained. Complete corneal epithelialization of the perforation was achieved in 2 months without visual compromises.

CONCLUSIONS

Cyanoacrylate tissue adhesive with iatrogenic incarceration of the autologous iris was effective in treating this type of small corneal perforation. This technique is simple and potentially useful for small paracentral corneal perforations outside the visual axis and without good apposition.

Clinical significance of owl eye morphologic features by in vivo laser confocal microscopy in patients with cytomegalovirus corneal endotheliitis

OBJECTIVE

To demonstrate the clinical significance of owl eye morphologic features observed by in vivo laser confocal microscopy in patients with cytomegalovirus (CMV) corneal endotheliitis.

DESIGN

Observational case series.

METHODS

participants: Six eyes of 6 patients (6 men; mean age, 73.3 years) with cytomegalovirus corneal endotheliitis diagnosed by clinical manifestations together with polymerase chain reaction from aqueous humor samples. intervention: All patients were examined by slit-lamp biomicroscopy and in vivo laser confocal microscopy. main outcome measures: Clinical manifestations were summarized by reviewing medical records. Selected confocal images of corneal layers were evaluated qualitatively for shape and degree of light reflection of abnormal cells and deposits.

RESULTS

All patients had long histories of anterior uveitis with intraocular pressure elevation, corneal edema with keratic precipitates, and decrease of endothelial cell densities. Coin-shaped lesions were observed by slit lamp only in 1 patient at the first visit and in 2 additional patients at subsequent follow-up. In all patients, confocal microscopy demonstrated reduced subepithelial nerves, subepithelial opacity, increased reflectivity of keratocytes, highly reflective dots, and needle-shaped bodies. Owl eye morphologic features were observed consistently in all patients at the initial visit, and highly reflective round bodies were detected in 5 patients; most notably, these confocal features were reversible after resolution of endotheliitis.

CONCLUSIONS

Owl eye morphologic features and highly reflective round bodies observed by confocal microscopy may be useful as an adjunct for the noninvasive diagnosis of cytomegalovirus corneal endotheliitis. Reversibility of these features after resolution of endotheliitis may be useful for monitoring the therapeutic effects without multiple anterior chamber tap.

Mathematical projection model of visual loss due to fuchs corneal dystrophy

PURPOSE. To devise a mathematical disease classification model for eyes with primary guttata cornea, on the bases of endothelial loss trajectory and probability of advanced disease. METHODS. A series of 1971 patients (3281 eyes), some with and some without guttata corneas, undergoing specular microscopy were retrospectively reviewed. The eyes were classified into four stages; stage 0, without guttae; 1, guttata cornea without edema; 2, mild Fuchs' corneal dystrophy (FCD); and 3, severe FCD, according to clinical records, and patient age and corneal endothelial cell density (ECD) were plotted. Nonparametric density smoothing was used to create a contour map, and a best-fit curve for ECD loss was calculated. The relation between ECD decrease rate and the stages were evaluated. RESULTS. Endothelial decrease rate in stage 0 was 0.44%/year, which was compatible with that of normal eyes reported in previous studies. Decrease rates of stages 1, 2, and 3 were 0.81%, 2.65%, and 3.08%/ year, respectively. The age-ECD loss curves of 1.40%/year (ECO(1.4)) and 2.00%/year (ECO(2.0)) further divided stage 1 into three subgroups; stage 1a, asymptomatic guttata cornea; 1b, borderline guttata cornea; and 1c, pre-FCD. The ECO(2.0) cutoff line differentiated eyes with FCD from those without edema with a sensitivity and specificity of >90%. Stage 1c eyes were below ECO(2.0) and had a decrease rate as high as FCD. CONCLUSIONS. This mathematical model can be used to predict the prognosis of patients with primary guttata cornea.

In vivo laser confocal microscopic analysis of murine cornea and lens microstructures

BACKGROUND AND OBJECTIVE

The purpose of the current study is to investigate in vivo microstructures of anterior segments of normal murine eyes by new-generation in vivo laser confocal microscopy.

MATERIALS AND METHODS

Twenty-six corneas and lenses from 13 mice were analyzed by in vivo laser confocal microscopy.

RESULTS

Murine corneal superficial cells formed a polygonal cell pattern, with a mean cell density of 577 +/- 115 cells/mm2 (mean +/- standard deviation). Corneal basal epithelial cells had dark cytoplasm and were closely organized (9,312 +/- 1,777 cells/mm2). Sub-basal nerve fiber bundles were arranged in a whorl pattern, with both clockwise and counter-clockwise patterns. In the stroma, keratocytes were observed as numerous reflective stellate structures. The endothelial cells were organized in a honeycomb pattern (2,463 +/- 292 cells/mm2). Deeper inside the eye, murine lens epithelial cells were organized in a regular pattern (4,168 +/- 636 cells/mm2) and numerous lens fibers were observed.

CONCLUSION

In vivo laser confocal microscopy can provide high-resolution images of all corneal layers and lens structures of mice without sacrificing animals or tissue preparation.

Non-Descemet stripping automated endothelial keratoplasty for endothelial dysfunction secondary to argon laser iridotomy

PURPOSE

To report clinical outcomes of non-Descemet stripping automated endothelial keratoplasty (nDSAEK) as treatment of endothelial dysfunction secondary to argon laser iridotomy (ALI).

DESIGN

Single-center, prospective, noncomparative, interventional case series.

METHODS

Six eyes of six patients (two men, four women; mean age, 74.5 years) with bullous keratopathies secondary to ALI were treated with endothelial keratoplasty without recipient Descemet stripping. The donor endothelial lamella was inserted using a pull-through technique using a Busin glide with intraocular lens glide (i.e., Kobayashi double-glide technique). Best-corrected visual acuity (BCVA), astigmatism, and donor central endothelial cell density (ECD) were recorded before surgery and at six months after surgery. Intraoperative and postoperative complications also were recorded. Main outcome measures were preoperative and postoperative central ECD, with calculation of cell loss rate. BCVA, induced astigmatism, and complications also were evaluated.

RESULTS

All patients reached more than 20/32 BCVA, with two (33.3%) reaching 20/20. Mean induced astigmatism in measurable cases was 0.85 +/- 0.49 diopters. The average and standard deviation ECD at six months were 2390.5 +/- 522.4 cells/mm(2) (range, 1589 to 2898 cells/mm(2)), representing a mean cell loss from preoperative donor cell measurements of 25.8% +/- 14.7%. Complications included one case of donor dislocation requiring rebubbling (16.7%) and one case of subclinical endothelial rejection (16.7%).

CONCLUSIONS

This modified endothelial keratoplasty technique (nDSAEK and double-glide technique) for treatment of endothelial dysfunction secondary to ALI produced excellent clinical outcomes such as reduced endothelial cell loss, good visual acuity, and minimal induced astigmatism.

In vivo laser confocal microscopy after descemet stripping with automated endothelial keratoplasty

PURPOSE

To investigate in vivo corneal changes in patients with bullous keratopathies before and after Descemet stripping with automated endothelial keratoplasty (DSAEK) using laser confocal microscopy.

DESIGN

Single-center, prospective, comparative clinical study.

METHODS

Seven patients (two men, five women; mean age, 68.9 years; range, 59 to 78) with bullous keratopathies who underwent DSAEK enrolled in this study. Laser confocal microscopy was performed before and one, three, and six months after DSAEK. Selected images were evaluated qualitatively and quantitatively for degree of haze and density of deposits.

RESULTS

Preoperatively, corneal epithelial edema, subepithelial haze, keratocytes in a honeycomb pattern, and tiny needle-shaped materials in the stroma were observed in all patients. After DSAEK, subepithelial haze, donor-recipient interface haze, and interface particles were observed in all five measurable cases; postoperative haze and particles decreased statistically significantly (P < .05) over follow-up.

CONCLUSIONS

In vivo laser confocal microscopy is capable of identifying subclinical corneal abnormality after DSAEK with high resolution. Further studies in a large number of patients and long-term follow-up after DSAEK using this device are needed to fully understand long-term corneal stromal changes after DSAEK and whether the preexisting corneal stromal pathologies are reversible.

Measurement of Light Transmission of Human Limbal Epithelial Cells Cultured on Human Amniotic Membranes

PURPOSE

To measure the light transmission properties of human limbal epithelial cell sheets (LECSs) cultured on human amniotic membranes (AMs) and compare them with those of AMs with and without amniotic epithelium.

METHODS

Total light transmission of 3 kinds of tissue (LECSs, intact AMs, denuded AMs) was measured in the 250- to 800-nm range by using a spectrophotometer.

RESULTS

The percent transmission of each kind of tissue decreased gradually and continually throughout the spectrum as the wavelength shortened and dropped rapidly at 300 nm to less than 20% at 250 nm. All tissues transmitted more than 70% of light in the wavelength region greater than 400 nm and more than 90% in that greater than 600 nm. The percent transmission spectrum of all tissues showed identical curves in the visible light and UV-A regions. However, the percent transmission of LECSs was lower than that of either intact or denuded AMs in the UV-B and UV-C regions.

CONCLUSIONS

In the visible and UV-A light region, the percent transmission profiles of amnion-related tissues (LECSs, intact AMs, denuded AMs) are not altered by the presence of either amniotic epithelium or multilayered limbal corneal epithelium. However, the presence of multilayered limbal corneal epithelium, but not amniotic epithelium, on amniotic stroma reduced UV-B and -C transmission significantly. Further study concerning light transmission and other physical properties of LECSs is necessary to fully understand the ocular physiology of eyes grafted with such newly developed bioengineered tissues.

Olfactory and gustatory disturbances caused by digitalism: A case report

It is known that an overdose of digoxin causes visual disturbance, but the effect on the senses of smell and taste is not known. A case of olfactory and gustatory disturbance caused by digitalism is reported. In a 62-year-old male patient suffering from chronic digitalism, the serum digoxin level rose to 6.0 ng/ml. The patient was diagnosed not only with visual disturbance but also hyposmia and hypogeusia. The patient recovered from visual and chemosensory disturbances after the serum digoxin concentration returned to normal. Because the similarity of intracellular signal transduction between photoreceptor cells and olfactory and/or taste receptor cells is known, it is suspected that the influence of digoxin to chemosensory organs was caused by intermediation of sodium-potassium-adenosine triphosphatase (Na-K-ATPase) of the chemosensory receptor cells.