Carla P. Nieuwendaal

A technique to excise the Descemet membrane from a recipient cornea (Descemetorhexis)

Objective: To describe a technique for excision of the Descemet membrane (DM) from the recipient eye for preparation of a recipient stromal bed in posterior lamellar keratoplasty. Methods: In 10 human eye bank eyes and 3 patients, recipient eyes had a 5.0-mm scleral tunnel incision made extending 1.0 mm into the peripheral cornea at the 12 o’clock surgical position. The anterior chamber was completely filled with air, and a reflective glide was placed through the incision onto the iris, to better visualize DM. A 9.0-mm mark was made onto the corneal epithelium to outline the area from which the Descemet membrane was to be removed. With a custom-made scraper, the DM was then carefully stripped off the posterior stroma by loosening the membrane at the 6 o’clock position and pulling it toward the incision at 12 o’clock. The excised DMs were evaluated by light and electron microscopy. Results: In all recipient eyes, DM could be easily and completely removed from the posterior corneal stroma. Microscopy showed isolated DMs without stromal tissue elements. Conclusion: With the technique described, DM can be excised in a controlled fashion without damaging the posterior corneal stroma, to quickly create a recipient stromal bed before implantation of a donor posterior lamellar disk in posterior lamellar keratoplasty.

Sutureless, posterior lamellar keratoplasty: a case report of a modified technique

Purpose. To describe a technique for sutureless, posterior lamellar keratoplasty. Methods. The procedure was performed for a case of pseudophakic bullous keratopathy. Through a 5.0-mm, self-sealing scleral tunnel incision, a stromal pocket was dissected across the cornea, just above Descemets membrane. An 8.5-mm diameter posterior lamellar disc, consisting of posterior stroma, Descemets membrane, and endothelium, was transplanted without suture fixation. Results. One week after surgery, the best spectacle corrected visual acuity (BSCVA) was 0.8 (20/25), with S −1.5 and C −1.0 × 85°. After 1 year, the posterior transplant was clear and in position, and the BSCVA was 0.8 with S −1.5 and C −1.75 × 80°. Pachymetry measured 0.60 mm. Endothelial cell counts averaged 1390 cells/mm2. Conclusion. Sutureless, posterior lamellar keratoplasty may be an effective new surgical approach for managing corneal endothelial disorders.

Posterior lamellar keratoplasty using descemetorhexis and organ-cultured donor corneal tissue (Melles technique)

Purpose: To report the clinical results of posterior lamellar keratoplasty (PLK) using predissected organ-cultured donor corneal tissue implanted after stripping of the Descemet membrane. Methods: Twenty-two eyes of 22 patients in whom a PLK procedure was performed for pseudophakic bullous keratopathy and/or Fuchs endothelial dystrophy were evaluated. In all eyes, the recipient Descemet membrane was excised by performing a descemetorhexis. Just after harvesting the donor tissue, each cornea had a posterior lamellar dissection made at approximately 80% stromal depth, and each cornea was preserved in an organ culture system for 10 to 21 days. During surgery, a posterior lamellar disk was trephinated from the predissected donor cornea and inserted through a 5.0-mm scleral incision into the anterior chamber of the recipient by folding the donor. Specular microscopy was performed at 6, 12, and 18 months to measure the endothelial cell density. Results: In 3 eyes (14%), the posterior donor disk did not attach to the recipient posterior stroma, so a penetrating keratoplasty was performed in a secondary procedure. The transplants in the remaining 19 eyes cleared and maintained clarity throughout the follow-up period. In these eyes, best corrected visual acuity (BCVA) ranged from 0.25 to 1.0 up to 27 months of follow-up. Postoperative astigmatism averaged 1.7 ± 1.0 D. Endothelial cell density averaged 1650 ± 390 cells/mm2 at 6 months, 1560 ± 350 cells/mm2 at 12 months, and 1500 ± 430 cells/mm2 at 24 months. Two eyes developed mild interface haze. Conclusion: PLK can be performed using an organ-cultured donor posterior disk. Visual rehabilitation may be slower than in PLK with fresh donor tissue.

Quality of Vision in Patients With Fuchs Endothelial Dystrophy and After Descemet Stripping Endothelial Keratoplasty

OBJECTIVE To evaluate the quality of vision (visual acuity and straylight) in patients with Fuchs dystrophy and the improvement in visual quality after Descemet stripping endothelial keratoplasty (DSEK). METHODS There was an observational case series (Amsterdam group) and a prospective interventional case series (Mayo group). Corrected distance visual acuity (CDVA), straylight, and corneal thickness were measured in patients with phakic and pseudophakic eyes with Fuchs dystrophy recruited at the Academic Medical Center, Amsterdam, the Netherlands (99 eyes), and at Mayo Clinic, Rochester, Minnesota (48 eyes). The Mayo group was also examined at 1, 3, 6, and 12 months after DSEK; all these eyes were rendered pseudophakic during DSEK. RESULTS Eyes with Fuchs dystrophy had decreased CDVA (mean [SD], 0.42 [0.26] logMAR; Snellen equivalent 20/53) and increased straylight (mean [SD], 1.54 [0.24] logarithm of the straylight parameter) compared with normal eyes. Younger patients were affected more by increased straylight than by decreased CDVA. Corrected distance visual acuity (r = 0.26; P = .003; n = 135) and straylight (r = 0.26; P = .003; n = 133) were correlated with corneal thickness. Corrected distance visual acuity and straylight improved at all postoperative examinations (P < .001), and improvement in straylight from before DSEK to 12 months after DSEK correlated with recipient age (r = -0.43; P = .01; n = 33). Improvement in straylight was more predictable than that of CDVA and was associated with preoperative straylight more than 1.33 logarithm of the straylight parameter. CONCLUSIONS Quality of vision is severely impaired in patients with Fuchs dystrophy and improves significantly after DSEK. Straylight improves more in younger than in older eyes after DSEK. Preoperative straylight can be a useful clinical metric to predict postoperative improvement, especially in cases where preoperative visual acuity is close to 20/20.

Comparison of a new-generation sectorial addition multifocal intraocular lens and a diffractive apodized multifocal intraocular lens.

PURPOSE: To compare visual, refractive, and satisfactory outcomes between a new‐generation sectorial addition multifocal intraocular lens (IOL) (Lentis Mplus LS‐312; study group) and a diffractive apodized multifocal IOL (Restor SN6AD1; control group). SETTING: Private practice, Driebergen, and Department of Ophthalmology, Academic Medical Center, Amsterdam, The Netherlands. DESIGN: Comparative case series. METHODS: Refractive and visual outcomes at near and distance, patient satisfaction, and dysphotopsia scores were recorded 3, 6, and 12 months postoperatively. RESULTS: The study group comprised 90 eyes and the control group, 143 eyes. Three months postoperatively, the mean uncorrected distance visual acuity (UDVA) was not statistically significantly different between the study group and the control group (0.04 ± 0.15 logMAR [SD] versus 0.06 ± 0.25 logMAR). The control group had significantly better uncorrected near visual acuity than the study group at 30 cm (0.05 ± 0.14 logMAR versus 0.15 ± 0.08 logMAR) and 40 cm (0.05 ± 0.14 versus 0.16 ± 0.21) (P<.01 and P<.03, respectively). Patients in the control group were more satisfied with their vision (P<.001). Dissatisfaction was related to younger age at surgery and male sex (P<.0001 and P<.033 respectively). Dysphotopsia occurred in approximately 18% of cases in both groups. CONCLUSIONS: The new sectorial addition multifocal IOL performed comparably to the diffractive apodized multifocal IOL in terms of UDVA and the presence of dysphotopsia. The diffractive apodized multifocal IOL performed better at 30 cm and 40 cm reading distances and had higher patient satisfaction. Financial Disclosure: Dr. Lapid‐Gortzak has received speaker’s fees from Alcon, Simovision, Oculentis, and Medtechnika. Dr. Lapid‐Gortzak and Dr. van der Meulen have received an unrestricted research grant from Oculentis. Dr. van Velthoven has received speaker’s fees from Novartis (Netherlands). Drs. van der Linden, Nieuwendaal, and Mourits have no financial or proprietary interest in any material or method mentioned.

Age-related risk factors, culture outcomes, and prognosis in patients admitted with infectious keratitis to two Dutch tertiary referral centers.

Purpose: To assess age-related risk factors (RFs), microbiologic profile, and prognosis of infectious keratitis and create guidelines for prevention and treatment. Methods: Retrospective review of patients with infectious keratitis admitted to 2 Dutch tertiary referral centers from January 2002 to December 2004. Results: Forty-nine patients were admitted to the Academic Medical Center (Amsterdam) and 107 to the Rotterdam Eye Hospital. Mean age was 56.6 ± 24.4 (SD) years; 49.4% were ≥60 years of age. The most common RFs among the elderly were systemic illness (36.4%), ocular surgery (33.8%), topical steroids (26%), blepharitis (20.8%), and herpetic eye disease (28.6%). This was significantly different from the most common RFs among younger patients (contact lens wear, 62.7%; χ2, P = 0.000). Gram-negative infections predominated (52.3%) and were more prevalent among younger patients (χ2, P = 0.000). Gram-positive infections prevailed among the elderly. Untreated patients had higher culture positive rates (68.7%) than patients treated with antibiotics before culturing (41.3%; χ2, P = 0.001). Elderly patients had a higher risk of perforations than younger patients (27.6% vs. 9.9%), a worse prognosis (mean VA, 6/30 vs. 6/10), and more often needed surgery (57.1% vs. 23.4%; P < 0.005 in all cases). Conclusions: Infectious keratitis is a more severe disease in elderly than in younger patients with more complications and a worse prognosis. Elderly patients have multiple and more diverse risk factors, making prevention difficult. Prevention should aim at minimizing topical steroid use and controlling blepharitis, ocular surface disease, and herpetic eye disease. Initial antibiotic treatment should include sufficient coverage of Gram-positive pathogens.

Thickness measurements of donor posterior disks after descemet stripping endothelial keratoplasty with anterior segment optical coherence tomography.

Purpose: To evaluate donor posterior disk thickness measured with anterior segment optical coherence tomography after Descemet stripping endothelial keratoplasty. Methods: Fifteen patients (17 eyes) after Descemet stripping endothelial keratoplasty, using manually dissected donor posterior disks, were measured with the Visante anterior segment optical coherence tomography (Carl Zeiss Meditec Inc, Dublin, CA). Optical coherence tomography scans were made in a radial pattern, 45 degrees apart, starting in the horizontal axis. Thickness measurements of the donor posterior disks were taken centrally and at fixed radii toward the periphery and were correlated to postoperative change in spherical equivalent (SE), best-corrected visual acuity (BCVA, in Snellen), and improvement in BCVA. Results: Median BCVA was 20/30 (range 20/60-20/20) postoperatively. Median postoperative improvement in BCVA was 4 lines (range 1-11). Median follow-up time was 15.5 months (range 6-32 months). Median postoperative change in SE was −0.25 diopters (range −4.25 to +3.00 diopters). Median central disk thickness was 128.3 μm (range 55-181 μm) and increased significantly toward the periphery: median disk thickness at the 1.5 mm radius was 140.8 μm (range 72-199 μm) and at the 3.0 mm radius was 161.5 μm (range 102-245 μm). No correlation was found between (central) donor disk thickness and postoperative BCVA or change in SE. A nonstatistically significant trend was seen toward more improvement in BCVA with thinner donor disks. Conclusions: Optical coherence tomography measurements of the manually dissected donor posterior disk showed significant variation in thickness, without a statistically significant effect on postoperative BCVA or improvement thereof. Central thickness varied significantly from the peripheral thickness within donor posterior disk.

Straylight measurements in contact lens wear.

Purpose: (1) To quantify the effect of contact lens wear on straylight in rigid and soft contact lens wearers and (2) to relate findings to morphological changes and subjective complaints. Methods: Straylight was measured using the Oculus C-Quant during contact lens wear and after contact lens removal in 30 rigid contact lens wearers and 30 soft contact lens wearers. Semi-quantitative (0-4) slit-lamp grading of anterior segment changes using Efron grading scales and contact lens characteristics were performed. Subjects answered a straylight questionnaire. Results: Soft contact lens wearers had a mean straylight of logarithmic value of the straylight parameter [log(s)] = 0.934 during contact lens wear and after contact lens removal [comparable to log(s) = 0.938 of age-matched normal eyes]. Rigid contact lens wearers had a mean straylight during contact lens wear of log(s) = 1.167. After contact lens removal, log(s) significantly decreased to 0.997 (P < 0.01). Straylight values with rigid contact lenses were strongly increased (P < 0.001) compared with age-matched normal eyes; after contact lens removal, these values decreased but remained elevated. Straylight in rigid contact lens wearers correlated with the amount of deposits on the contact lens (P < 0.01) but not with other variables of the contact lens score. The questionnaire showed more straylight complaints in rigid contact lens wearers than in soft contact lens wearers (P < 0.01). Conclusions: Rigid contact lens wear leads to increased straylight during contact lens wear and after contact lens removal. This may be because of subclinical effects of contact lens wear on the cornea and is not seen in soft contact lens wearers.

Localized opacification of hydrophilic acrylic intraocular lenses after procedures using intracameral injection of air or gas

Purpose To describe clinical and laboratory findings in a series of cases of intraocular lens (IOL) opacification after procedures involving intracameral injections of air or gas. Setting John A. Moran Eye Center, University of Utah, Salt Lake City, Utah, USA. Design Experimental study. Methods Seven hydrophilic acrylic IOLs explanted after Descemet‐stripping endothelial keratoplasty (DSEK) or Descemet‐stripping automated endothelial keratoplasty (DSAEK) because of a localized central optic opacification associated with decrease in visual acuity and complaints of foggy vision were analyzed. The explanted IOLs were sent to our laboratory in the dry state or in fixative by the explanting surgeons. They underwent pathological and histochemical evaluation (alizarin red and von Kossa method). Light scattering measurements were also performed on the surface of 1 explant using Scheimpflug photography. A questionnaire was sent to the surgeons to obtain information pertinent to each case. Results The 7 explanted IOLs were represented by 6 hydrophilic acrylic designs from 5 manufacturers. Gross and light microscopy showed that granular deposits were densely distributed in an overall round pattern within the margins of the capsulorhexis or the pupil on the anterior surface/subsurface of the IOLs. The granules stained positive for calcium (alizarin red and von Kossa method). Light scattering on the anterior optic surface was very high (228 versus 13 computer‐compatible tapes on a control IOL). Conclusions A localized pattern of calcification was seen on the anterior surface/subsurface of various hydrophilic acrylic IOLs. Surgeons should be aware of this phenomenon following DSEK/DSAEK procedures in pseudophakic patients with hydrophilic acrylic IOLs. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

Straylight measurements in laser in situ keratomileusis and laser-assisted subepithelial keratectomy for myopia

PURPOSE: To compare straylight values before and 3 months after laser in situ keratomileusis (LASIK) and laser‐assisted subepithelial keratectomy (LASEK) and to analyze the causes of any change. SETTING: Private refractive surgery clinic, Driebergen, The Netherlands. METHODS: Straylight was measured before and after LASIK or LASEK with a C‐Quant straylight meter; values were recorded as the straylight parameter log(s). Main outcome measures were the difference between postoperative and preoperative straylight values and factors causing a difference between the values. RESULTS: The study evaluated 102 eyes having LASIK and 137 eyes having LASEK. On average, there was significant improvement in straylight values postoperatively in both groups. The mean decrease was −0.016 log(s) in the LASIK group and −0.026 log(s) in the LASEK group. Nonparametric testing (sign test) showed that the improvement in straylight was statistically significant in more than 50% of eyes in both groups. Straylight improved in 62 eyes in the LASIK group (P<.001) and 78 eyes in the LASEK group (P<.02) and deteriorated in 35 eyes and 58 eyes, respectively. There was an increase in straylight in 17 eyes (7.1%). Clinical correlations were found in some eyes that had increased postoperative straylight values. CONCLUSION: On average, straylight values 3 months after LASIK and LASEK were slightly decreased from baseline values. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned. Additional disclosures are found in the footnotes.