Asim Ali

Corneal neurotization from the supratrochlear nerve with sural nerve grafts: a minimally invasive approach.

Summary: Corneal anesthesia is a debilitating condition which can ultimately lead to blindness from repetitive corneal injury and scarring. We have developed a minimally invasive technique for corneal re-innervation that we have used with excellent results in ten eyes. This article and accompanying video describes the relevant anatomy and demonstrates the technique in detail.

Corneal Fine Needle Diathermy With Adjuvant Bevacizumab to Treat Corneal Neovascularization in Children.

Purpose: To report the outcomes of corneal fine needle diathermy (FND) with adjuvant intrastromal and subconjunctival bevacizumab injection for corneal neovascularization (CN) in children. Methods: Medical records of all children who had undergone FND with adjuvant bevacizumab injection were reviewed retrospectively. Treatment efficacy was evaluated by changes in visual acuity, regression of CN, and clearing of lipid deposits with the aid of slit-lamp color images that were taken before surgical intervention and at last follow-up visit. Postoperative complications were recorded and served to assess the safety of the procedure. Results: Nine eyes of 9 patients were included in the study. The mean age of the patients was 8.4 ± 4.2 years (4–15 years) and the mean follow-up time was 18.7 ± 12.2 months (5–35 months). Three eyes had a history of herpes simplex keratitis (HSK), 3 eyes had complete corneal anesthesia, 2 eyes had CN following suture tract infection after corneal transplant for HSK scar and limbal dermoid excision, and 1 eye had blepharokeratoconjunctivitis. After treatment, 8 eyes had complete CN resolution, and 1 eye with corneal anesthesia following brain tumor resection had partial regression in vessel distribution and size. Lipid deposition clearance lagged behind CN resolution. Mean duration of CN before treatment was 15.3 ± 14.0 months (1–37 months). Mean corrected distance visual acuity before and after surgery was 0.66 ± 0.31 and 0.50 ± 0.37 logMAR, respectively (P = 0.02). Conclusions: Corneal FND with adjuvant bevacizumab injection is effective at treating sectorial corneal vessels in children.

Long-Term Corneal Endothelial Cell Counts After Penetrating Keratoplasty in Infants.

Purpose: To report long-term endothelial cell counts after penetrating keratoplasty (PKP) in infants. Methods: The charts of all children who have undergone PKP in their first year of life between 1998 and 2013 at the Hospital for Sick Children, Toronto, Canada, were reviewed retrospectively. Patients who had a single successful transplant with a valid endothelial cell density (ECD) analysis postsurgery were included in the study. Donor ECDs were provided by a local eye bank. Specular microscopy images were taken at a variable interval after surgery using a noncontact specular microscope (ROBO, Konan; Konan Medical) and endothelial cell loss was calculated. In young children images were taken in the lateral decubitus position under general anesthesia. Results: Twenty-one eyes of 16 patients were included in the study. Median patient age at the time of surgery was 2.0 months [mode, 2.0; interquartile range (IQR), 1.6–2.6 months] and median follow-up time was 49.0 months (IQR, 33.0–99.5 months). The most common indication for surgery was Peters anomaly, in 16 eyes (76.2%). Ten eyes had additional intraocular surgeries posttransplant. The median ECDs prekeratoplasty and at last follow-up were 2958 cells per square millimeter (IQR, 2807–3205 cells/mm2) and 1307 cells per square millimeter (IQR, 946–1613 cells/mm2) respectively, reflecting a median endothelial cell loss of 59.2% (IQR, 44.3%–68.8%). Iris adhesions to the graft–host junction were strongly associated with low final ECD (P = 0.01). Conclusions: Despite technical challenges and difficult postoperative care, pediatric keratoplasty is associated with a lower endothelial cell loss over time compared with that reported in adults after PKP.

In Vivo Confocal Microscopy Reveals Corneal Reinnervation After Treatment of Neurotrophic Keratopathy With Corneal Neurotization

Purpose: To document the presence and location of new sensory nerve fibers after corneal neurotization using in vivo confocal microscopy (IVCM) in 2 patients with neurotrophic keratopathy (NK). Methods: Two patients with unilateral advanced NK received corneal neurotization to surgically reinnervate the cornea. IVCM was used to identify subbasal nerve fibers and document corneal reinnervation. In 1 patient (case 1), IVCM was performed before and after corneal neurotization; in the second patient (case 2), IVCM was performed after neurotization and corneal transplantation. Results: In case 1, who had hand motion visual acuity due to NK-associated corneal perforation that necessitated cyanoacrylate gluing, preoperative IVCM identified no subbasal nerves; however, subbasal nerves were identified 6 months after corneal neurotization, and there were no further episodes of persistent epithelial defects. In case 2, in whom NK with a total absence of corneal sensation was the result of treated basal skull meningioma, corneal sensation, visual acuity, and ocular surface health improved after corneal neurotization. Deep anterior lamellar keratoplasty was performed 2.5 years after corneal sensation was reestablished. IVCM demonstrated corneal reinnervation at the stromal and subbasal level in a pattern different from the normal cornea. Conclusions: Corneal neurotization restores corneal sensation by reinnervating the stromal and subbasal layers of the cornea. In doing so, corneal neurotization may halt the process of NK and prevent further visual loss.

Successful Treatment of Acute Ocular-Involving Toxic Epidermal Necrolysis Using Amniotic Membrane Suture Fixated to Custom Designed Symblepharon Rings.

Purpose: The purpose of this study is to describe a novel technique using amniotic membrane suture-fixated onto custom-designed symblepharon rings in a patient with acute toxic epidermal necrolysis (TEN). Methods: A 61-year-old man developed bilateral symblephara and severe ocular surface inflammation from Stevens-Johnson syndrome/TEN secondary to allopurinol. Eight days after admission, he was treated with placement of custom-designed symblepharon rings, designed by one of the authors (A.A.), covered with amniotic membrane. This method was used to allow for efficient placement of the membrane and to minimize operative time and perioperative risks due to his worsening systemic condition. Results: On postoperative day 49, his visual acuity was 20/20 in the right eye and 20/25 in the left eye. Both eyes were quiet with only small symblephara noted temporally. Conclusions: The use of amniotic membrane suture-fixated to custom-designed symblepharon rings provides sufficient coverage of the ocular surface, leading to excellent visual and clinical outcomes by reducing inflammation and protecting the ocular surface from the cicatrizing sequelae associated with ocular-involving TEN. This novel technique is less invasive, more time efficient, and likely safe for even the most critically ill patients with significant risk for mortality, thus allowing any treating ophthalmologist to comfortably perform this important sight-saving procedure.

Refractive and visual outcomes after surgery for pediatric traumatic cataract

PURPOSEnTo describe refractive and visual outcomes of pediatric traumatic cataract requiring surgery and evaluate the factors influencing success.nnnSETTINGnHospital for Sick Children, Toronto, Ontario, Canada.nnnDESIGNnRetrospective case series.nnnMETHODSnCharts of children having lensectomy for traumatic cataract between January 1, 2000, and June 30, 2015, were reviewed for demographic information, visual and refractive outcomes, complications, and surgical details.nnnRESULTSnOne hundred six children (mean age 7.6xa0yearsxa0±xa03.9 [SD]) were included. The median follow-up was 41xa0months (range 3 to 155xa0months). Seventy-nine children had open-globe injuries and 27 had closed-globe injuries. Patients with open-globe injuries were younger than those with closed-globe injuries (mean age 6.9 versus 10.4xa0years; Pxa0<xa0.05). The final corrected distance visual acuity (CDVA) was 20/40 or better in 47 children. In the 94 children who had intraocular lens placement, 54% with open-globe injuries and 55% with closed-globe injuries achieved a mean absolute prediction error of 1.0 diopter or less in the early postoperative period. Open-globe injuries and amblyopia were associated with worse visual outcomes (odds ratio [OR], 2.8 and Pxa0=xa0.03 versus OR, 2.4 and Pxa0=xa0.04) and refractive outcomes (OR, 3.1 and Pxa0=xa0.02 versus OR, 3.8 and Pxa0=xa0.04). Age younger than 5xa0years was associated with worse refractive outcomes (OR, 2.88; Pxa0=xa0.02).nnnCONCLUSIONSnChildren requiring surgery for traumatic cataract can have good visual and refractive outcomes. Those with open-globe and those with closed-globe injuries both had good early postoperative refractive accuracy. Sixty-three percent of children with closed-globe injuries attained a CDVA of 20/40 or better at the final follow-up.

Anatomic characteristics of supraorbital and supratrochlear nerves relevant to their use in corneal neurotization

BackgroundCorneal denervation can lead to opacification and blindness. A new treatment technique, surgical corneal neurotization, transfers healthy donor nerve, (most commonly contralateral supratrochlear or supraorbital) to the affected limbus to prevent corneal destruction and improve healing potential of the cornea following insult. We examine gross and histomorphometric anatomy of the supratrochlear and supraorbital nerves relevant to their use in corneal neurotization.MethodsFor each of nine adult cadaver heads, bilateral supraorbital and supratrochlear nerves were dissected from the supraorbital rim to the anterior hairline. The following data were recorded for each nerve: exit from the orbit through a notch versus foramen; horizontal distance from midline at the supraorbital rim; and distance from orbital exit to first branching point. Samples of all left supraorbital and supratrochlear nerves were obtained at the level of the supraorbital rim and at points 3u2009cm and 6u2009cm distally for histomorphometric analysis. Myelinated axon counts were determined for each sample.ResultsFour supraorbital foramina, 14 supraorbital notches, two supratrochlear foramina, and 15 supratrochlear notches were identified. Average supraorbital and supratrochlear distances to midline were 26.5u2009mm and 21u2009mm respectively. Average myelinated axon counts for both nerves were greater at the orbital rim (supraorbital: 6018, supratrochlear: 2533) than at 6u2009cm distally (supraorbital: 1621, supratrochlear: 1112).ConclusionsAnatomic dissection shows relative close approximation of the supraorbital and supratrochlear nerves, with a high proportion of both nerves exiting the orbit through foramina. The supraorbital nerve at the orbital rim contains the greatest number of myelinated axons.

Abstract 13: Documentation Of Improved Ocular Surface Health After Corneal Neurotisation And Reinnervation Using Magnetoencephalography And Histology

RESULTS: In vivo, Fmod mouse wounds representing a lost-of-function model presented markedly increased myofibroblasts after wound closure compared with wild-type (WT) controls. Intradermal injection of FMOD representing gain-of-function models led to significantly decreased myofibroblast accumulation in the wound areas of multiple animal species, including WT mice and Fmod mice, rats and pigs with high-mechanical loading wounds. Moreover, FMOD injection significantly stimulated Il1β expression, which likely contributed to the diminished number of myofibroblasts. In vitro, FMOD alone stimulated myofibroblast (but not fibroblast) apoptosis as effectively as IL1β. Remarkably, even in the presence of TGFβ1 that completely blocked the effect of IL1β, FMOD promoted myofibroblast apoptosis. Meanwhile, IL1 receptor antagonist (IL1RA) fully rescued myofibroblasts from FMOD-induced apoptosis and blocked FMOD-stimulated myofibroblast IL1β expression. Thus, FMOD selectively promoted apoptosis of myofibroblasts but not fibroblasts via an IL1β-dependent pathway.