Carolina Betancurt

Use of Intraocular Videoendoscopic Examination in the Preoperative Evaluation of Keratoprosthesis Surgery to Assess Visual Potential

PURPOSE To determine the clinical utility of intraocular videoendoscopy examination for the evaluation of the retina and optic nerve in patients being considered for a Boston type I keratoprosthesis (KPro). DESIGN Interventional case series study. METHODS Ten patients with a history of corneal blindness caused by failed penetrating keratoplasty (PK) and inability to accurately assess visual potential were included in this study. Ophthalmologic examination, B-scan ultrasonography, and pars plana videoendoscopy were carried out to assess the retina and optic nerve before KPro. RESULTS Posterior segment examination was successfully used to evaluate the retina and optic nerve of all patients with opaque corneas. Out of 10 patients that underwent endoscopic examination, 3 (30%) were considered to be adequate candidates for KPro surgery and 7 (70%) were not. This was based on visualized retinal disease and/or optic nerve pathology. Of the 3 patients that underwent KPro surgery, all of them had a significant improvement of vision, including counting fingers to 20/100, hand motion to 20/5, and light perception to 20/80, as suggested by the endoscopy preoperative examination. No complications of the endoscopy procedure were observed. CONCLUSIONS This report demonstrates the successful use of intraocular videoendoscopy to rule out threats to a good visual outcome for patients being considered as candidates for KPro. Direct visualization of the posterior segment can be part of the preoperative algorithm in the decision process of performing a KPro surgery in patients when visual potential is questionable.

Ultra high resolution optical coherence tomography in Boston type I keratoprosthesis

Purpose: To evaluate the anterior keratoprosthesis-cornea interface in eyes with Boston type I keratoprosthesis (Kpro). Methods: In a prospective non-interventional study, patients with Boston type I Kpro underwent ultra-high resolution optical coherence tomography (UHR-OCT) evaluation. The images were used to measure and describe characteristics of the anterior keratoprosthesis-cornea interface, epithelial interaction at the keratoprosthesis edge and the keratoprosthesis-cornea interface gap. Results: Ten patients including 4 male and 6 female subjects with different preoperative diagnoses, i.e. 8 multiple corneal graft failures and 2 immunological ocular surface diseases, were studied. Mean age was 62.1 ± 20.0 (range, 33.0-83.0) years and mean interval between surgery and UHR-OCT evaluation was 15.2 ± 11.09 months. In eight patients, 360° epithelial growth over the peripheral edge of the Kpro was documented. We detected keratoprosthesis-cornea interface gap in three patients. One subject had developed postoperative endophthalmitis 8 months after surgery and the other two cases were among the high risk group according to the preoperative diagnosis. In one patient with severe ocular hypotony, the Kpro edge was inserted into the anterior stroma and covered with epithelium. Conclusion: UHR-OCT showed that corneal epithelium covers the Kpro edge and seals the potential space between the Kpro and cornea in 80% of cases. The presence of a gap in the interface and lack of epithelial sealing around the Kpro edge might be associated with endophthalmitis.

Management of Patients With Confirmed and Presumed Mucous Membrane Pemphigoid Undergoing Entropion Repair

PURPOSE To describe the outcomes and medical management necessary to achieve successful lid surgery in patients with biopsy-confirmed and presumed mucous membrane pemphigoid. DESIGN Retrospective, interventional case series. METHODS We included patients with positive biopsy results and cases with a typical clinical active bilateral presentation with negative biopsy results but classic features. We identified 11 operated eyes of 7 patients with lid malposition resulting from mucous membrane pemphigoid, particularly cicatricial entropion, that required surgical correction. Complete ophthalmologic history and examination were performed. The main outcome measures were control of ocular inflammation, progression of disease, and surgical success. RESULTS A bandage lens was used in 8 (72.7%) eyes to protect the cornea while immunosuppression and control of disease activity were achieved. Control of ocular inflammation before lid surgery was achieved in all cases. Immunosuppressive treatment before lid surgery was used in all cases for a mean of 15.1 months (range, 8.2 to 33.1 months) and after surgery for a mean of 6.6 months (range, 3.0 to 11.2 months). The oral immunosuppressive drugs used were mycophenolate and cyclophosphamide. Prednisone was used concomitantly in 4 (57%) patients. Full surgical success was achieved in all patients, with 1 patient requiring a second intervention because of residual disease. The mean postoperative follow-up period was 20.8 months (range, 6.0 to 30.5 months). CONCLUSIONS Successful entropion repair in patients with mucous membrane pemphigoid can be achieved if control of inflammation is attained before the procedure. Ocular surface protection while achieving disease control is essential in the management of these patients.

Combined Conjunctival Autograft and Overlay Amniotic Membrane Transplantation; a Novel Surgical Treatment for Pterygium

The authors report the long-term results of combined conjunctival autograft and overlay amniotic membrane transplantation (AMT) for treatment of pterygium as a new surgical technique. Nineteen patients including 12 male and 7 female subjects with pterygium (primary, 14 cases; recurrent, 5 cases) underwent combined conjunctival autograft and overlay AMT and were followed from 10 to 26 months. Mean age was 44.21±12.49 (range, 29.0-73.0) years. In one patient with grade T3 primary pterygium, the lesion recurred (5.2%, recurrence rate). No intra-and postoperative complication developed. This procedure seems a safe and effective surgical technique for pterygium treatment. Protection of the ocular surface during the early postoperative period reduces the friction-induced inflammation and might be helpful to prevent the recurrence.

Anterior Segment Manifestations of Microscopic Polyangiitis

In this retrospective, non-comparative case series, the medical records of three patients diagnosed with microscopic polyangiitis (MPA) at the Bascom Palmer Eye Institute, Ocular Surface/Uveitis service were analyzed: an 80-year-old female with episcleritis, peripheral ulcerative keratitis, and lung involvement (patient 1); an 83-yearold female with nodular non-necrotizing scleritis (patient 2); and a 19-year-old female with chronic conjunctivitis and nasal inflammation (patient 3). Patient 1 had a diagnosis of MPA on presentation to our service; despite steroid-sparing therapy, she required steroids to treat the ocular flare-up of MPA. Patient 2 was given an MPA diagnosis with the help of rheumatology, based on clinical signs, symptoms and a positive p-ANCA; she was treated with corticosteroids and methotrexate. Patient 3 was diagnosed with MPA based on a second biopsy performed by ENT and a positive p-ANCA; treatment with corticosteroids and methotrexate was initiated. MPA can have conjunctival, episcleral, scleral, and corneal manifestations. Even if lung or renal involvement is not noted clinically, a patient in whom there is a high suspicion for MPA should still undergoes a thorough systemic workup, including a biopsy. Furthermore, a multi-disciplinary approach should be taken when managing these patients in order to avoid vision and life-threatening complications. Microscopic polyangiitis (MPA) is a necrotizing small-vessel vasculitis. Patients are typically male, middle-aged, and develop nonspecific, constitutional signs and symptoms of inflammation. Characteristic features include glomerulonephritis, pulmonary vasculitis, and circulating perinuclear antineutrophil cytoplasmic antibodies (p-ANCA) with myeloperoxidase specificity (MPO). While MPA can affect various parts of the peripheral and central nervous systems, and ophthalmic involvement has been previously reported in scattered reports, ocular findings have not been well documented. MPA is a severe disease with the mortality as high as 27.5%; thus, treatment with immunosuppressant is generally necessary. In this article, we report our experience with three MPA patients who presented with atypical demographics and various ophthalmic findings.