Adi Einan-Lifshitz

Enhancing Descemet Membrane Endothelial Keratoplasty in Postvitrectomy Eyes With the Use of Pars Plana Infusion

Purpose: To present a modified surgical technique to perform Descemet membrane endothelial keratoplasty (DMEK) in previously vitrectomized eyes and to analyze its safety and efficacy. Methods: A retrospective analysis of previously vitrectomized eyes that underwent DMEK at Toronto Western Hospital was performed. The modified DMEK technique that was used included placement of a posterior pars plana infusion to reduce fluctuations in the anterior chamber depth and its excessive deepening. Results: Twelve eyes of 12 patients (5 females and 7 males) aged 65.3 ± 21.5 years were included. Mean best-corrected visual acuity improved significantly from 1.72 ± 0.62 logMAR (mean Snellen ∼20/1040) preoperatively to 1.01 ± 0.64 logMAR (mean Snellen ∼20/200) at 6 months postoperatively (P = 0.017). Mean donor endothelial cell density was 2658 ± 229 cells/mm2 preoperatively and 1732 ± 454 cells/mm2 at 6 months after the procedure (mean percentage cell loss of 31.8%) (P = 0.046). There were no significant intraoperative complications, and no graft failures. One eye had graft detachment, which resolved after 2 rebubbling procedures. One eye had retinal detachment, which was corrected surgically. Conclusions: The use of posterior pars plana infusion in previously vitrectomized eyes stabilizes the anterior segment during DMEK, allowing for performance of DMEK surgery, and can potentially reduce intraoperative and postoperative complications.

Comparison of Femtosecond Laser-Enabled Descemetorhexis and Manual Descemetorhexis in Descemet Membrane Endothelial Keratoplasty

Purpose: To introduce a novel method to perform descemetorhexis in Descemet membrane endothelial keratoplasty (DMEK) using the femtosecond laser and to compare it with Descemet membrane endothelial keratoplasty performed with manual descemetorhexis (M-DMEK). Methods: A retrospective medical chart review of 2 groups of patients who underwent DMEK surgery combined with cataract surgery secondary to Fuchs corneal endothelial dystrophy and cataract: 17 patients underwent femtosecond laser-enabled descemetorhexis Descemet membrane endothelial keratoplasty (FE-DMEK) and 89 patients underwent DMEK surgery with M-DMEK. Best spectacle-corrected visual acuity, endothelial cell density (ECD), graft detachment rate, and complications were compared. Results: Average age of the 106 patients (64 women and 42 men) was 68 ± 11 years. Postoperative best spectacle-corrected visual acuity was 0.19 ± 0.13 logarithm of the minimum angle of resolution in the FE-DMEK group and 0.35 ± 0.48 logarithm of the minimum angle of resolution in the M-DMEK group (P = 0.218). One day after surgery, there were no significant graft detachments in the FE-DMEK group, compared with 20% graft detachment rate in the M-DMEK group (P = 0.041). Rebubbling was performed in 17% of eyes in the M-DMEK group compared with none in the FE-DMEK group (P = 0.066). The mean endothelial cell count in the FE-DMEK and M-DMEK groups at 6 months after surgery were 2105 ± 285 cells per square millimeter (24% cells loss) and 1990 ± 600 cells per square millimeter (29% cells loss), respectively (P = 0.579). Conclusions: FE-DMEK shows efficacy similar to that of M-DMEK with apparently less graft detachment and reduced need for rebubbling.

Peripheral Blunt Dissection: Using a Microhoe-Facilitated Method for Descemet Membrane Endothelial Keratoplasty Donor Tissue Preparation

Purpose: To describe a modified technique for Descemet membrane donor tissue preparation that facilitates the original Melles stripping technique. Methods: Descemet membrane is prepared using a Rootman/Goldich modified Sloane microhoe, using a blunt instrument as opposed to a sharp blade or needle and begins dissection within the trabecular meshwork. The trabecular tissue is dissected for 360 degrees, and then Descemet membrane is stripped to approximately 50%. A skin biopsy punch is then used to create fenestration in the cornea, which is used to mark an “F.” on the stromal side of Descemet membrane to aid in orientation of the graft. Trephination of the membrane is then performed and stripping is completed. The tissue is stained with 0.06% trypan blue and aspirated into an injector for insertion into the anterior chamber. Results: Before converting to the technique described, 5 of 75 (6.7%) tissues were wasted and 7 of 75 (9.3%) tissues with radial tears were salvaged for use. Since converting to the new technique, only 1 of 171 (0.6%) (P = 0.01) tissues was wasted and 7 of 171 (4.1%) (P = 0.2) tissues with radial tears were salvaged. Conclusions: The peripheral blunt dissection technique offers an improvement over the technique originally described by Melles et al, as the incidence of tissue wastage and tears is lower, it is easy to learn, has low stress, and is reproducible. Combining this with a stromal surface letter mark ensures correct orientation of the tissue against the corneal stroma of the recipient.

Macular Corneal Dystrophy and Posterior Corneal Abnormalities

Purpose: This study reports the presentation of 2 families with macular corneal dystrophy (MCD). The aim of this study was to show whether ultrasound biomicroscopy (UBM) can, based on posterior changes of the cornea in MCD, assist in the choice of surgery, either anterior lamellar keratoplasty (DALK) or penetrating keratoplasty (PK), compared with optical coherence tomography (OCT) and Scheimpflug. Methods: Six patients with MCD were examined for their best-corrected visual acuity, slit-lamp, OCT, UBM, and Scheimpflug findings. Blood samples for DNA and exons of the CHST6 gene were screened for mutations. Results: All 6 patients showed typical MCD signs at the slit lamp. Corneal transplantation was required in 2 patients in both eyes. Recurrence of MCD was observed in 2 eyes after the DALK procedure (patient A5, age 48 years, right eye and B1, 51 years, left eye), whereas the 2 eyes after PK (patient A5, age 48 years, left eye and patient B1, 51 years, right eye) remained clear (for 10 years of follow-up in patient A5 and 4 years in patient B1). In 2 patients (A1 and A3), corneal thinning could be evaluated by OCT. In 3 patients (A2, 3, and 4), UBM disclosed deeper pathologies including opacities, loss of continuity, and focal protrusions of the posterior cornea, which were not evident by other devices. In family A, a novel mutation was identified. Conclusions: Our UBM examination of MCD shows alterations of the corneas posterior layer and confirms the known clinical and histological findings of MCD that PK represents the therapy of choice, contrary to DALK. The novel CHST6 mutation shows the heterogeneity of MCD.

Simple limbal epithelial transplantation for recurrent pterygium: A case series

Purpose Pterygium recurrence is a common complication of pterygium removal. Multiple surgical and medical approaches have been utilized to reduce recurrence rates. The present case series proposes a novel way to treat recurrent pterygia, by using the simple limbal epithelial transplantation (SLET) technique. Observations The cases of four patients who presented with recurrent pterygium were reviewed. In all four of the cases reported, the SLET procedure went without complication. There were no significant recurrences at each of the patients most recent follow-up visits. Conclusions and importance This is the first report of SLET being used as a treatment modality for recurrent pterygium. Further studies are required to more reliably demonstrate the utility of the procedure in this clinical circumstance, but our results are encouraging that in select patients, this may be a viable option in treating aggressive recurrent pterygia.

Bilateral BrightOcular iris implants necessitating explantation and subsequent endothelial keratoplasty

Purpose To demonstrate the dangers associated with the BrightOcular iris implant, a model that had initially been touted as safer than its predecessors. Observations A 41-year-old male presented with decreased vision in both eyes, approximately two years following bilateral BrightOcular cosmetic iris implantation performed in Mexico. On initial consultation, he was found to have bilateral corneal decompensation with stromal edema and a significantly reduced endothelial cell count (ECC). On follow up 5 weeks later, his vision and corneal edema had further detriorated. In the following month, he underwent explantation of the cosmetic iris implants in both eyes. Significant corneal edema persisted in the right eye several months post-operatively, to the point of necessitating endothelial keratoplasty. Conclusions and importance Despite numerous reports in the literature of the significant ocular complications that can arise secondary to cosmetic iris implantation, individuals continue to willingly undergo this surgery. Our intention with presenting this case to the ophthalmologic community is two-fold: to highlight the ongoing clinical risk that BrightOcular devices pose, despite being marketed as safer than the older NewColourIris models, and to stress the urgency with which cosmetic iris implants should be removed from the eye.

Topography-Guided Photorefractive Keratectomy in the Treatment of Corneal Scarring.

PURPOSE To report the outcome of topography-guided photorefractive keratectomy (TG-PRK) in the treatment of patients with corneal scarring. METHODS A retrospective, interventional case series including 6 eyes of 6 patients with corneal scarring and irregular astigmatism who underwent TG-PRK. The etiologies for scarring were: infectious corneal ulcers, foreign body trauma, LASIK flap buttonhole, and lamellar keratoplasties performed to correct corneal perforation secondary to corneal melting. Main outcome measures were corrected distance visual acuity, uncorrected distance visual acuity, manifest refraction, and corneal regularity on topography maps. RESULTS Average age was 56.5 ± 19.6 years and average follow-up time was 14.8 ± 6.1 months. Three patients had corneal scarring with cataract and underwent TG-PRK to achieve sufficient regularization of corneal astigmatism to enable the implantation of a toric intraocular lens (IOL). The three remaining patients had TG-PRK performed to improve visual acuity, and all had improvement in uncorrected (improvement between one and three Snellen lines) and corrected (improvement between two and three Snellen lines) distance visual acuity. There were no intraoperative or postoperative complications and no loss of visual acuity. CONCLUSIONS The use of TG-PRK for corneal scarring may improve visual acuity in selected cases, obviate the need for keratoplasty in some cases, and facilitate toric IOL implantation in some cases. [J Refract Surg. 2017;33(9):639-644.].