Cataract surgery in setting of ocular surface disease

PURPOSE OF REVIEW

The purpose of this article is to review the available strategies to successfully identify and manage ocular surface disease (OSD) pre, intra and post-cataract surgery.

RECENT FINDINGS

Cataract surgery and OSD have an intricate relationship: the surgical procedure can induce or exaggerate OSD symptoms, while OSD can negatively impact surgical refractive outcomes and increase the rate of postoperative complications.

SUMMARY

Improving the health and stability ocular surface is the key to enhance post cataract surgery refractive outcomes and avoid complications. This is pivotal for patients affected by severe OSD, but is also important for patients with minimal signs or symptoms. A correct diagnosis and a stepwise approach are the keys to improve the quality of life of such patients.

Deep Anterior Lamellar Keratoplasty: Can All Ruptures Be Fixed?

PURPOSE

The aim of this study was to report our experience in managing different types of Descemet membrane (DM) ruptures during deep anterior lamellar keratoplasty (DALK).

METHODS

This study was a retrospective, consecutive, interventional case series of 1573 DALK procedures conducted on 1244 patients, performed between 2002 and 2017. Inclusion criteria consisted of a minimum of 24-month follow-up. DM rupture incidence, location, and surgical approach for repair were recorded. Postoperative measures were investigated only in eyes that experienced DM ruptures and included best spectacle-corrected visual acuity, endothelial cell loss, double anterior chamber, pupillary block, need for rebubbling, graft clarity, and rejection episodes.

RESULTS

One thousand four hundred forty-three eyes met the inclusion criteria. DM ruptures occurred in 119 eyes (8.25%). Seventy-eight percent of DM ruptures were microruptures (≤2 mm), and they occurred more frequently during manual DALK cases. Macroruptures were less frequent (22%), and they occurred more frequently during subtotal and total anterior lamellar keratoplasty (STALK-TALK) cases. In general, DM ruptures mainly occurred in the peripheral cornea (95% of cases). One hundred (84%) of the 119 ruptures resolved by the first postoperative day. Nineteen cases (16%) developed double anterior chamber; all resolved by using different strategies. No intraoperative penetrating keratoplasty conversion was recorded. Pupillary block occurred in 7 cases (5.9%), but no Urrets-Zavalia syndrome was observed. The average postoperative endothelial cell loss was 410 ± 39 cells/mm 2 (19%) at 1-year follow-up, and there was no significant difference between cases requiring a rebubbling and cases that did not ( P = 0.896). All grafts but one were clear at the last follow-up. Graft failure from endothelial decompensation occurred in this lone case (0.8%).

CONCLUSIONS

It is worth trying to repair all DM ruptures in DALK, and immediate penetrating keratoplasty conversion should be avoided. Understanding the physiomechanical mechanisms in DALK allows to correctly choose a proper rescue strategy to successfully repair DM ruptures.

Rediscovering a valuable manual Deep Anterior Lamellar Keratoplasty (DALK) technique: Outcomes of 42 "Peeling-off" DALK

PURPOSE

Residual bed thickness in DALK should be less than 80μm to provide optimal visual outcomes. "Peeling-off" is a manual DALK technique, which separates the anterior stroma by pulling the deep stromal lamellae following the plane of their lowest adhesion, which is usually very deep. The purpose of this study is to measure the residual bed thickness achievable with this technique.

METHODS

Retrospective case series of "Peeling-off" DALK cases performed between January 2014 and January 2021 with at least 1 year of follow-up. Indications for DALK, intraoperative and postoperative complications, residual recipient bed thickness at 1 day and at 1 month after surgery, and postoperative best corrected visual acuity (BCVA) at 1 year of follow up were evaluated.

RESULTS

42 eyes (42 patients) underwent DALK performed with "Peeling-off" technique. Indications for surgery were keratoconus in 33 eyes and stromal scar in 9 eyes. "Peeling-off" technique was used as a rescue approach to perform a DALK after a failed Big-Bubble in all cases, and also failed Air-Visco-Bubble in some cases. No intraoperative and postoperative complications were recorded. Residual recipient bed thickness was deep and regular, measuring 42 microns at 1 day postoperative (range 21-65 microns) and 23 microns (range 17-26 microns) at 1 month postoperative. Mean postoperative BCVA at 1 year of follow up was 0.18 logMAR ± 0.09.

CONCLUSION

"Peeling-off" DALK is a valuable manual technique that achieves a deep stromal plane with optimal visual outcomes.

Deep anterior lamellar keratoplasty for corneal penetrating wounds

PURPOSE

To report our surgical experience of deep anterior lamellar keratoplasty (DALK) performed in eyes with scarring resulting from a corneal penetrating wound without tissue loss.

METHODS

Case series of three eyes of three patients that underwent DALK for poor vision due to a scar resulting from a previous corneal penetrating wound. Surgery was performed at least 1 year after the initial injury. Manual dissection technique was used in all cases. Preoperative and postoperative best correct visual acuity (BCVA), postoperative residual bed thickness, and postoperative endothelial cell count (ECC) were evaluated.

RESULTS

Preoperative BCVA ranged from 1.3 to 1.0 LogMAR. Two eyes were pseudophakic and one eye had a traumatic cataract. Manual DALK was successfully accomplished in all three cases. The mean residual recipient bed thickness was 103 µm (range 68-130 µm). The mean endothelial cell loss at the 6th month of follow-up was 6% (range 3%-11%) with a further 1% decrease at 4 years. One of the patients underwent cataract surgery and limbal relaxing incisions 1 year after DALK having a total endothelial cell loss of 4.8% at 2 years of follow-up. BCVA at 2 years of follow-up was 0.1 LogMAR (range 0.22-0.0 LogMAR). No episode of rejection was recorded, and all grafts remained clear at last follow-up (5 years, range 4-6 years).

CONCLUSIONS

Manual DALK should be considered in cases of corneal scars in optical zone resulting from penetrating wound.

Total or subtotal full thickness recipient bed cut to repair donor-recipient curvature disparity in cases of DM rupture with manual DALK

PURPOSE

To report how to manage a specific type of Descemet's membrane (DM) rupture during manual DALK with a concurrent donor-recipient disparity of curvature.

METHODS

Case report of two patients that had DM rupture during manual DALK with a concurrent donor-recipient disparity of curvature; the recipient bed was flatter (post-infectious scar, case 1) and steeper (keratoglobus, case 2) than the donor. Preoperative diagnosis, clinical exam, and best spectacle correct visual acuity (BSCVA) have been reported. A subtotal full-thickness circular cut of the recipient bed was performed to resolve a persistent double AC in case 1 (recipient flatter than donor). A total full-thickness circular cut of the recipient bed, creating a graft made by a DALK allograft and a "DSEK autograft," was performed to avoid a refractory double AC in case 2 (recipient steeper than donor). Evaluated outcomes included postoperative BSCVA, endothelial cell count (ECC), graft clarity, rejection, and presence/absence of double AC.

RESULTS

Surgery was successful in resolving/avoiding double AC. VA improved in both cases. No episodes of rejection were recorded. Graft remained clear at the last follow-up (6 years for case 1 and 4 years for case 2).

CONCLUSION

The existence of a donor-recipient curvature disparity should be investigated as a possible underlying mechanism of refractory double AC. Total or subtotal full thickness recipient bed cut may be considered to repair donor-recipient curvature disparity in cases of DM rupture occurring during manual DALK. Repairing the DM rupture and avoiding a conversion to PK in high-risk transplant cases are crucial.

Manual deep anterior lamellar keratoplasty after partial unintentional full-thickness trephination

PURPOSE

The aim of this study was to describe a surgical technique to perform deep anterior lamellar keratoplasty (DALK) despite inadvertent full thickness trephination in one quadrant.

METHODS

Case report of a 19-year-old boy who underwent DALK for visually significant post-infectious stromal scar in his left eye. An unintentional full thickness trephination occurred in the upper-nasal quadrant at the beginning of the surgery. After suturing the perforated area, manual DALK was performed, and an air bubble was left in the anterior chamber. Evaluated outcomes included best spectacle corrected visual acuity (BSCVA), residual recipient bed thickness, endothelial cell count (ECC), graft clarity, rejection, and presence/absence of double anterior chamber.

RESULTS

The surgery was completed without any further complications. No double anterior chamber or Urrets-Zavalia syndrome was observed on the first postoperative day. Mean residual recipient bed thickness was 72 μm and regular. ECC was 2446 cell/mm². BSCVA at 18 months of follow-up was 0.9. There were no episodes of rejection, and the graft remained clear at the last follow-up (4 years).

CONCLUSION

Inadvertent partial full thickness trephination of the recipient cornea is a largely preventable but possible complication during DALK. Penetrating keratoplasty conversion can be avoided by performing a manual dissection DALK.

Suture pull-through insertion of graft donor in Descemet stripping automated endothelial keratoplasty: Results of 4-year follow-up

Purpose:

To report our clinical experience and 4-year follow-up results of Descemet stripping automated endothelial keratoplasty (DSAEK) with the suture pull-through insertion technique.

Methods:

This is a retrospective study of 195 eyes in which a posterior lamellar keratoplasty was performed between 2007 and 2011. The insertion of a folded donor lenticule was performed with a double-armed 10-0 suture using a straight transchamber needle and half-circle needle. Endothelial cell density was measured annually up to 4 years after the surgery, and cell loss was calculated based on the median preoperative donor endothelial cell density. Postoperative complications, primary graft failure, pupillary block, and dislocation of the donor tissue were assessed.

Results:

All patients underwent uncomplicated DSAEK. Data were available for 195 eyes (100%) at 1 year, 186 eyes (95.3%) at 2 years, 176 eyes (90.2%) at 3 years, and 160 eyes (82%) at 4 years. Median preop-erative donor endothelial cell density was 2688 cells/mm² [interquartile range (IQR) 207.5 cells/mm²], which decreased by 27% at 1 year (1956 cells/mm², IQR 264.8 cells/mm²), 31% at 2 years (1855 cells/mm², IQR 320.5 cells/mm²), 35% at 3 years (1756.5 cells/mm², IQR 306.5 cells/mm²), and 36% at 4 years (1709.5 cells/mm², IQR 288,0 cells/mm²). Nine patients (4.6%) had a dislocation of donor tissue; all were successfully reattached with a second air injection. Only three eyes (1.5%) developed graft failure. Pupillary block was present in 15 eyes (7.7%).

Conclusion:

DSAEK with suture pull-through insertion of donor graft represents a simplified and safe technique that has endothelial cell loss comparable with other techniques and low rates of intraoperative and postoperative complications.

Genotype of inflammatory cytokines in limbal stem cell graft in Italian patients

We tested the hypothesis that the genetic capability to mount an inflammatory response might contribute to the inter-individual variability of limbal stem cell graft (LSCG) outcome. Two functional polymorphisms in the IL-6 and TNF-alpha promoter regions were genotyped in 35 patients. A new score system (clinical assessment score, CAS) was set up in order to classify patients' clinical profile, and the main parameters relevant for LSCG as well as for the follow-up of the patients. Patients carrying at both loci a genotype associated with a lower production of both cytokines were classified as "low producers" (LP), while all the others were classified as "intermediate or high producers" (HP). LP patients did not show any difference in CAS before and after transplantation while a significant difference was present in HP patients. A similar trend was evident in the 35 months of follow-up. Polymorphisms of IL-6 and TNF-alpha can be used to identify subgroups of patients with higher risk of unsuccessful outcome.