Clara C. Chan

Ab externo scleral suture loop fixation for posterior chamber intraocular lens decentration: Clinical results

PURPOSE: To evaluate the efficacy and safety of an ab externo suture retrieval and scleral fixation technique in the treatment of subluxated posterior chamber intraocular lenses (PC IOLs). SETTING: Academic tertiary care centers. METHODS: Surgical databases from 2 surgeons were reviewed for consecutive cases from March 2000 to April 2004 in which the ab externo scleral suture fixation technique was used and a minimum follow‐up of 3 months was completed. Patient charts were reviewed for 15 eyes that had decentered in‐the‐bag PC IOLs, 12 eyes with subluxated sulcus or bag–sulcus positioned PC IOLs, and 3 eyes with PC IOLs dislocated into the vitreous. RESULTS: The mean time from cataract extraction to PC IOL stabilization was 3.4 years (range 2 days to 10.9 years). Surgical repositioning was successfully performed in all patients. After a mean follow‐up of 14.7 months, the mean best corrected visual acuity (BCVA) improved from 20/140 to 20/40 (P = .0001). All patients had stable or improved BCVA. All patients with a successfully completed procedure achieved an adequately centered PC IOL postoperatively. One patient (3.3%) developed a significant intraoperative vitreous hemorrhage requiring the procedure to be aborted, but reoperation 3 months later was successful. Postoperative complications included persistent elevated intraocular pressure in 2 eyes (6.7%) and chronic cystoid macular edema in 1 eye (3.3%) that resolved with medication. CONCLUSION: The ab externo suture loop retrieval and scleral fixation technique was effective in repositioning decentered, subluxated, or dislocated PC IOLs with excellent visual outcomes.

Accelerated (9-mW/cm2) corneal collagen crosslinking for keratoconus-A 1-year follow-up.

Purpose: The aim of this study was to assess the efficacy of accelerated crosslinking (irradiance of 9 mW/cm2; 10 minutes) in keratoconus-affected eyes through topographical, visual, and refractive end points. Methods: Mild-moderate keratoconus-affected eyes that underwent accelerated corneal collagen crosslinking (CXL) treatment and had 6 and 12 months of follow-up were reviewed retrospectively. Data regarding uncorrected distance visual acuity (UDVA), manifest refraction, corrected distance visual acuity (CDVA), and computerized corneal topography data before surgery and post-CXL treatment were extracted and analyzed. Results: Sixteen eyes of 14 patients were included in the study. The mean patient age was 24.9 ± 5.8 years (range: 17.1–38.3 years). No statistically significant changes were found in the mean CDVA, mean refractive cylinder, or mean manifest refraction spherical equivalent at either time point. There was a gain of 0.13 logarithm of the minimum angle of resolution lines in the mean UDVA (P = 0.012) at 12 months. All corneal parameters including Ksteep, Kflat, average K (Km), corneal astigmatism (Kcyl), and maximal curvature reading at the corneal apex (Kmax) were stable at 6 and 12 months in all patients. No complications were observed during the follow-up period. Conclusions: Accelerated corneal CXL is effective in stabilizing topographic parameters after 12 months of follow-up in mild-moderate keratoconus-affected corneas. Improvement in the UDVA and stabilization of all tested corneal parameters were noted after the treatment. However, a longer follow-up with larger cohorts is necessary to validate these findings.

Infectious keratitis after Boston type 1 keratoprosthesis implantation.

Purpose: To determine the incidence, clinical features, and outcomes of infectious keratitis after Boston type 1 keratoprosthesis (Kpro) implantation. Methods: Ten cases of infectious keratitis were identified in a retrospective chart review of 105 patients (126 eyes) who received Kpro between November 2004 and November 2010 at the Cincinnati Eye Institute and were followed for at least 1 month (range, 1–66 months; mean, 25 months). Results: The incidence was 7.9%. Patient diagnoses included 4 chemical injuries, 3 Stevens–Johnson syndrome, 2 ocular cicatricial pemphigoid, and 1 congenital aniridia. Kpro implantation was indicated in 2 eyes for a failed ocular surface and in 8 for penetrating keratoplasty failure. Four patients were contact lens intolerant or noncompliant. All were on topical vancomycin and moxifloxacin for prophylaxis and 2 were on topical amphotericin for prophylaxis. Three infiltrates were culture negative, 5 were fungal (3 Candida, 1 Fusarium, 1 Dactylaria constricta), and 2 were bacterial (Rhodococcus equi and Gram-negative cocci). All patients were managed with topical agents and 4 were given an oral antifungal agent. Four patients had Kpro removal with therapeutic penetrating keratoplasty and 1 had Kpro replacement. At final follow-up, only 2 patients retained their preinfection best vision. Risk factors for infectious keratitis included a diagnosis of cicatrizing conjunctivitis (Stevens–Johnson syndrome, ocular cicatricial pemphigoid, or chemical injury) and a history of persistent epithelial defect (P = 0.0003 and 0.0142, respectively). Contact lens wear, vancomycin use, and a history of systemic immunosuppression (or use at the time of infection) were not statistically significant risk factors. Conclusions: Infectious keratitis after Kpro can occur even when patients are on vancomycin and a fourth-generation fluoroquinolone for prophylaxis. Fungal organisms are a growing cause for concern, and we present the details of the first reported case of ocular D. constricta. The evolution of our management and prophylaxis strategy for fungal keratitis after Kpro implantation is also described.

Infectious endophthalmitis after Boston type 1 keratoprosthesis implantation.

Purpose To determine the incidence, clinical features, and outcomes of infectious endophthalmitis after Boston Type 1 Keratoprosthesis (KPro) implantation. Methods Retrospective, consecutive case series. Chart review of 105 patients (126 eyes) who had KPro implantation at Cincinnati Eye Institute between November 2004 and November 2010 and who were followed up for at least 1 month (range, 1 month to 66 months; mean 25 months) revealed 3 cases who developed infectious endophthalmitis. Results One patient had a history of congenital glaucoma, and 2 patients had Stevens–Johnson syndrome. Two had KPro implantation for penetrating keratoplasty failure and 1 had necrosis of a previous KPro cornea. The incidence of endophthalmitis was 2.4%. All patients wore a contact lens and were on vancomycin and a fourth-generation fluoroquinolone (moxifloxacin). Vitreous fluid cultures yielded Ochrobactrum anthropi, Candida parapsilosis, and Candida albicans. All patients received intravitreal amphotericin, vancomycin, and/or ceftazidime. Topical and oral antiinfective agents were tailored based on sensitivities. One patient required KPro removal and therapeutic penetrating keratoplasty. Vision did not recover for 2 patients who presented with vision decreased to light perception. One patient, who presented with decreased vision of 20/400, recovered to 20/60. Conclusions Infectious endophthalmitis is a devastating complication that can occur after Boston KPro implantation even with prophylactic vancomycin, a fourth-generation fluoroquinolone, and a therapeutic contact lens. Fungal and gram-negative organisms are a growing cause for concern. Further study is needed on optimal prophylaxis regimens, including the use of antifungals, especially for high-risk eyes, such as those with autoimmune cicatrizing disease.

Femtosecond laser-assisted mushroom configuration deep anterior lamellar keratoplasty.

Purpose: To review patient outcomes after femtosecond laser-assisted mushroom configuration deep anterior lamellar keratoplasty. Methods: Seven eyes of seven patients with a mean age of 30 years underwent femtosecond laser-assisted mushroom configuration deep anterior lamellar keratoplasty from April 2008 to September 2008. Patients had keratoconus, corneal ectasia or scarring. Set for 100 μm of residual cornea, the femtosecond laser was used to create a mushroom-shaped recipient bed and donor button (having a larger anterior than posterior diameter). The posterior central lamella was manually dissected using Melles technique. Results: Mean follow up was 4 months (range, 3-6.5 months). Preoperative mean best-corrected visual acuity was 20/95 (range, 20/40-20/400). Intraoperative complications included two cases (28.6%) of small Descemet membrane perforation. Postoperatively, there was one case of stromal rejection that resolved with topical steroids and two cases of steroid-related intraocular pressure rise that were treated with a prostaglandin analog. At 3 months, mean best-corrected visual acuity was 20/40 (range, 20/25-20/60), mean spherical equivalent refraction was −3.21 D (range, −6.75 D to plano), mean cylindrical refractive error was 3.57 D (range, 1.5-7 D), and mean keratometric cylinder measured 5.56 D (range, 3.79-7.00 D). Selective suture removal occurred in six patients (86%) at a mean of 3.8 months (range, 2-6 months) postoperatively. Conclusions: This preliminary series demonstrates that the use of the femtosecond laser to perform corneal cuts in a mushroom configuration for deep anterior lamellar keratoplasty is feasible. The mechanical stability and wound healing advantages for stepped corneal wounds should be considered in lamellar surgery.

Comparison between femtosecond laser mushroom configuration and manual trephine straight-edge configuration deep anterior lamellar keratoplasty

Aim To compare outcomes and complications of femtosecond laser (FSL) mushroom configuration and manual trephine (MT) straight-edge configuration deep anterior lamellar keratoplasty (DALK). Methods A cohort of 19 consecutive eyes that underwent FSL DALK was compared with 19 consecutive eyes that underwent MT DALK. Surgery was performed for eyes with keratoconus, corneal ectasia and scarring. Patient demographics, best-corrected visual acuities (BCVAs), refraction and complications were compared. Results Groups were comparable for age, gender and preoperative BCVA. Rates of intraoperative and postoperative complications were low and comparable between the groups. These included intraoperative Descemets membrane (DM) perforation which did not require conversion to penetrating keratoplasty; stromal rejection successfully treated with topical steroids; postoperative DM detachment; delayed epithelial healing and increased intraocular pressure which resolved with topical anti-glaucoma drops. At 3 months, the mean BCVA was significantly better in the FSL group compared with the MT group (p=0.00002). At 6 months and 1 year, there was no significant difference between mean BCVA between the two groups. Mean spherical equivalent, cylindrical astigmatism and keratometric cylinder preoperatively and at 3, 6 and 12 months postoperatively were similar between the two groups. Conclusions FSL or trephine DALK are viable options for keratoconus, ectasia and corneal scars. Earlier visual recovery occurs with FSL mushroom configuration compared with MT straight-edge DALK.

The modified Cincinnati procedure: combined conjunctival limbal autografts and keratolimbal allografts for severe unilateral ocular surface failure.

Purpose: To describe the technique and present the outcomes of combined conjunctival limbal autografts (CLAU) and keratolimbal allografts (KLAL) for the treatment of unilateral severe ocular surface failure. Methods: Interventional case series. Eleven eyes of 11 patients who sustained chemical burns (4 alkali and 2 acid) and combined chemical/thermal burns (5 eyes) from firework explosions had combined CLAU/KLAL surgery. Keratoplasty was performed subsequently for residual corneal stromal scarring limiting visual acuity. Inclusion criteria included eyes with severe unilateral total ocular surface failure, controlled glaucoma, and reasonable eyelid apposition with no exposure. Exclusion criteria included patients with any ocular surface abnormality in the fellow eye and those with contraindications to systemic immunosuppression (SI). Outcome measures included Snellen best-corrected visual acuity (BCVA), ocular surface stability, SI exposure, and complications. Results: Preoperative BCVA was 20/400 or worse in all eyes. At the final follow-up (mean, 35.8 months; range, 12.1–105.9 months), 73% (8 of 11) eyes had BCVA of 20/80 or better (range, 20/25 to counting fingers), and ocular surface was stable in 82% (9 of 11). Ninety-one percent (10 of 11) had additional penetrating keratoplasty (PK) with a 60% (6 of 10 eyes) success rate. Three cases had subsequent Boston type 1 keratoprosthesis implantation after PK failure, and the fourth patient, at the time of his last follow-up visit, did not want further intervention for his edematous PK, which was a result of noncompliance-related corneal rejection. In eyes with more than 2 years of follow-up, SI was tapered at a mean of 16 months (range, 8–28 months). There were no intraoperative complications. No secondary tumors, cardiac events, or deaths occurred while patients were on SI. One patient developed secondary glaucoma refractory to medical management after subsequent PK, requiring cyclodiode laser. Conclusions: Combined CLAU/KLAL and staged keratoplasty is effective in improving vision and maintaining long-term ocular surface stability in patients with severe unilateral ocular surface disease and conjunctival deficiency.

Ocular surface stem cell transplantation rejection: incidence, characteristics, and outcomes.

Purpose: To describe the incidence, characteristics, risk factors, treatment, and outcomes of ocular surface stem cell transplantation (OSST) rejection. Methods: A chart review of patients who had OSST at a single institution between 1998 and 2010 was performed. Data were collected on patient demographics, type of OSST procedure, duration of immunosuppression, and rejection characteristics. Main outcome measures were ocular surface stability and improvement in best-corrected visual acuity. Results: Two hundred twenty-two eyes of 158 patients were included with mean follow-up of 62.7 months (range, 12.0–158.3 months). The most common indications for OSST were aniridia (46.4%), chemical/thermal injury (22.1%), and Stevens–Johnson syndrome (12.2%). The most common procedures performed were keratolimbal allograft (KLAL) alone (80.6%) and combined living-related conjunctival allograft (lr-CLAL)–KLAL (11.3%). Mean time on immunosuppression was 44.3 months (range, 7.6–138.2 months). Severe rejection occurred in 43 eyes (19.4%) with mean time to rejection being 15.2 months (range, 0.2–93.1 months). Low-grade rejection occurred in 26 eyes (11.7%) with mean time to rejection being 26.2 months (range, 1.3–64.9 months). At the final follow-up, 36.6% of eyes in the rejection group achieved a stable ocular surface compared with 71.9% of eyes in the nonrejection group (P < 0.0001). Risk factors associated with increased risk of rejection were younger age (P < 0.0001), KLAL alone (P = 0.049), and noncompliance with immunosuppression (P = 0.047). Conclusions: Ocular surface outcomes for patients with OSST rejection are poor, with the majority of patients having failed ocular surfaces despite treatment with increased immunosuppression and repeat OSST. It is critical for success that OSST patients are closely monitored for rejection and for compliance with immunosuppression.

Severe Limbal Stem Cell Deficiency From Contact Lens Wear: Patient Clinical Features

PURPOSE To describe characteristics of patients with severe limbal stem cell deficiency associated with contact lens (CL) wear. DESIGN Retrospective case series. METHODS Database search of patients with severe limbal stem cell deficiency related to CL wear was conducted. The charts of 12 patients (18 eyes) were reviewed. Outcome measures included patient demographics, CL type, duration of wear, indications for wear, symptoms, location and laterality of limbal stem cell deficiency, coexisting ocular disease, and treatment. RESULTS Mean patient age at presentation was 42 years (range, 19 to 58 years), and 8 patients (67%) were female. Mean duration of CL wear was 14.1 years (range, 1 to 20 years), 6 patients (50%) had bilateral disease, and all wore soft CLs for refractive error correction. Vision was decreased to a mean of 20/78 (range, 20/30 to 20/250) in all eyes. Fifteen eyes (83%) had photophobia, pain, or both. Findings leading to the diagnosis included whorl-like epitheliopathy, corneal conjunctivalization, and late fluorescein staining of the involved epithelium for at least 6 clock hours. On average, 10 clock hours (range, 6 to 12 clock hours) were involved, and 11 eyes (61%) had total ocular involvement. Conservative treatments failed in all eyes. Fourteen eyes (78%) underwent limbal stem cell transplantation with systemic immunosuppression. CONCLUSIONS Severe limbal stem cell deficiency related to CL wear is a clinical diagnosis that an ophthalmologist should recognize. Female patients, soft CLs, and extended duration of wear time are associated with this condition. Conservative measures may not reverse the disease, and limbal stem cell transplantation with systemic immunosuppression is a surgical option for these young and healthy patients.

Medically Reversible Limbal Stem Cell Disease: Clinical Features and Management Strategies

PURPOSE To describe the clinical features and management strategies in patients whose limbal stem cell (LSC) disease reversed with medical therapy. DESIGN Retrospective case series. PARTICIPANTS Twenty-two eyes of 15 patients seen at 3 tertiary referral centers between 2007 and 2011 with 3 months or more of follow-up. METHODS Medical records of patients with medically reversible LSC disease were reviewed. Demographic data, causes, location and duration of disease, and medical inventions were analyzed. MAIN OUTCOME MEASURES Primary outcomes assessed included resolution of signs of LSC disease and improvement in visual acuity. RESULTS Causes of the LSC disease included contact lens wear only (13 eyes), contact lens wear in the setting of ocular rosacea (3 eyes), benzalkonium chloride toxicity (2 eyes), and idiopathic (4 eyes). Ophthalmologic findings included loss of limbal architecture, a whorl-like epitheliopathy, or an opaque epithelium arising from the limbus with late fluorescein staining. The superior limbus was the most common site of involvement (95%). The corneal epithelial phenotype returned to normal with only conservative measures, including lubrication and discontinuing contact lens wear in 4 patients (4 eyes), whereas in 11 patients (18 eyes), additional interventions were required after at least 3 months of conservative therapy. Medical interventions included topical corticosteroids, topical cyclosporine, topical vitamin A, oral doxycycline, punctal occlusion, or a combination thereof. All eyes achieved a stable ocular surface over a mean follow-up of 15 months (range, 4-60 months). Visual acuity improved from a mean of 20/42 to 20/26 (P < 0.0184). CONCLUSIONS Disturbances to the LSC function, niche, or both may be reversible with medical therapy. These cases, which represent a subset of patients with LSC deficiency, may be considered to have LSC niche dysfunction.