Damien Guindolet

Unusual Severe Interface Inflammation After Uneventful Small Incision Lenticule Extraction (SMILE)

PURPOSE To describe a 40-year-old woman who complained of visual loss in her left eye 3 days after an uneventful bilateral myopic refractive surgery by small incision lenticule extraction (SMILE). METHODS Case report. RESULTS A 4 × 5 mm anterior central stromal infiltration was observed with moderate pain associated with decreased corneal sensitivity and neither discharge nor fluorescein staining. Bacterial and fungal smears and cultures from the SMILE interface were negative and local antibiotic ineffective. She was subsequently treated with peribulbar dexamethasone injections and oral valacyclovir. Corneal infiltration disappeared progressively, replaced by fibrotic stromal scarring. Optical coherence tomography displayed stromal hyperreflectivity mostly located above the lenticule cut with slight involvement of posterior stroma. In vivo confocal microscopy demonstrated activated keratocytes and highlighted the lack of subbasal corneal nerves in her left eye contrasting with her right eye. CONCLUSIONS Stromal herpetic keratitis could be considered a potential differential diagnosis to this atypical lamellar keratitis after a SMILE procedure. [J Refract Surg. 2016;32(12):855-857.].

Double Docking Technique for Femtosecond Laser-Assisted Deep Anterior Lamellar Keratoplasty

Purpose: To describe a new and safe surgical technique of deep anterior lamellar keratoplasty (DALK) using the femtosecond laser (FSL) and intraoperative optical coherence tomography (iOCT) for surgical management of corneal thinning and/or opacities. The technique was coined the double-docking procedure for DALK (DD-DALK). Methods: FSL-integrated iOCT was used for direct visualization and calibration to perform precise anterior lamellar and side cuts for the removal of the anterior stroma. Air was then injected in the residual posterior stroma to detach Descemet membrane [big-bubble (BB) formation]. Returning the residual posterior stroma into the docked position, a cylindrical vertical cut was made with the FSL to securely open the BB roof. Next, the stromal roof of the BB was removed with forceps leaving Descemet membrane intact, followed by a lamellar corneal graft. Results: Anterior stroma resection, BB formation, and residual stromal resection were achieved in every case without perforation. The curved applanation surface helped to limit the formation of folds on the posterior stroma (ie, advanced thinning). Conclusions: DD-DALK is a reproducible and safe procedure for surgical management of corneal thinning and/or opacities. The precision of stromal cuts made by the FSL and iOCT guidance for air injection increases success in DD-DALK preparation.

Storage of Porcine Cornea in an Innovative Bioreactor

Purpose To quantify cell survival and tissue structure preservation of porcine cornea stored in a bioreactor (BR) that recreates a transcorneal pressure gradient equivalent to intraocular pressure (IOP) and renews the medium. Methods A BR comprising endothelial and epithelial chambers was machined in a biocompatible material. The porcine cornea, securely held, separated the chambers. Medium flow and pressure inside the endothelial chamber were maintained by a peristaltic pump. In the epithelial chamber, the corneal surface was alternatively exposed to air and a specific medium. Two transparent windows allowed thickness measurement by optical coherence tomography without opening the BR. Porcine corneas stored in the BR-on (pressure 20 mm Hg, flow 5 μL/min, temperature 31°C) were compared with (1) BR-off (no pressure or flow); (2) organ culture; and (3) Petri dish with agar on the endothelial side. Epithelial and limbal structure and differentiation, corneal transparency and thickness, and endothelial viability were compared after 7 days of storage and with fresh corneas. Results Corneas stored in the BR-on were thinner and more transparent than those stored with the other methods. The BR-on preserved a stratified and differentiated (K3/K12+) corneal epithelium and undifferentiated basal limbal cells with stemness markers (K3/K12-; ABCB5, K14, p75+), as well as endothelial integrity. Conclusions By recreating equivalent IOP and medium renewal, the BR obtained unprecedented storage quality of porcine corneas and preserved their main epithelial, limbal, and endothelial characteristics.

Sclerocorneal Intrastromal Lamellar Keratoplasty for Pellucid Marginal Degeneration.

Purpose: Surgical management of advanced pellucid marginal degeneration is challenging. To correct both corneal thinning and induced corneal astigmatism, we propose a modified intrastromal lamellar sclero-keratoplasty. Methods: Corneal thinning was mapped using perioperative optical coherence tomography (OCT). Then through a scleral tunnel, an intrastromal pocket was created by stromal lamellar dissection under OCT guidance. A 300 &mgr;m-thick stromal lamellar graft was inserted in that pocket before closing the sclera to increase vertical median keratometry. Results: Intrastromal lamellar sclero-keratoplasty enabled corneal thinning correction and increased corneal astigmatism correction (−11.6 diopters) without complications. Conclusions: Intrastromal lamellar keratoplasty with scleral tunnel is efficient in PMD. Corneal thinning is corrected with the intrastromal lamellar keratoplasty, and scleral tunnel closure allows increased corneal astigmatism correction. Perioperative OCT guidance allows better detection of the diseased cornea and is helpful for the lamellar dissection.

Cataract Surgery with Primary Lens Implantation in Children with Chronic Uveitis

ABSTRACT Purpose: To evaluate the evolution of chronic uveitis in children undergoing cataract surgery with primary intraocular lens (IOL) implantation. Methods: Twelve children with chronic uveitis underwent cataract surgery with primary posterior chamber intraocular lens (IOL) implantation. Results: Fourteen eyes were implanted with a foldable hydrophobic acrylic IOL. The mean follow-up was 35.39 months (8.72–69.57). The mean BCDVA before surgery and at the end of follow-up was 1.11 (0.40–2.30; SD: 0.57) and 0.48 (0–3; SD: 0.77; p=0.007) respectively. The mean oral corticosteroids dosage after surgery and at the end of follow-up was 0.80 mg/kg/day (SD: 0.37) and 0.17 mg/kg/day (SD: 0.24; p=0.001) respectively. All patients except one were treated with methotrexate. Four patients (5 eyes) were additionally treated with anti-tumor necrosis factor agent. Conclusions: Cataract surgery with primary posterior chamber hydrophobic IOL implantation is possible and leads to a good visual recovery in cases of pediatric chronic uveitis. This surgery requires aggressive anti-inflammatory management with immunosuppressive drugs to control inflammation and reduce the corticosteroids dosage.

Artificial chamber and 3D printed iris: a new wet lab model for teaching Descemet's membrane endothelial keratoplasty

To describe a new wet lab model of Descemet membrane endothelial keratoplasty (DMEK) using human corneas mounted on an artificial anterior chamber with an artificial iris and to compare the performance time and scores between beginners and experienced anterior segment surgeons.

Asymptomatic neurotrophic keratitis in carotid-cavernous fistulae

PPV group (mean 54 12 versus 59 9 years; p = 0.01), this small effect cannot explain the large difference found between SB and PPV. Moreover, 82%of patients in the SB group received cryotherapy, which is known to increase flare (Veckeneer et al. 2001). In conclusion, these results imply a more serious inflammatory reaction and a larger breakdown of the ocular barriers after PPV, which might contribute to better functional results after SB and a higher risk of PVR after PPV.

Management of severe and refractory Mooren's ulcers with rituximab

Purpose Management of severe and refractory Moorens ulcers is challenging as it encompasses tectonic surgical treatment and aggressive immunosuppressive therapies. Efficacy of rituximab in the management of severe Moorens ulcers has never been reported. Methods Five patients (six eyes) from the Cornea and External Disorders department at the Rothschild Ophthalmologic Foundation (Paris, France) were treated for severe Moorens ulcer unresponsive to conventional treatments between 2008 and 2016. Conventional treatment included topical steroid and ciclosporin 2%, high doses of systemic corticosteroids and/or cyclophosphamide and conjunctival resection with amniotic membrane graft. These patients received two infusions of 1000 mg of rituximab at 2 weeks interval. Epithelial healing, inflammation, additional surgery, systemic corticosteroids and rituximab-related side effects were reported. Results The mean follow-up was 46.8 months. Following rituximab treatment, we observed a complete healing of Moorens ulcer within 2 weeks in all patients. Peripheral lamellar keratoplasty was associated when peripheral corneal perforation occurred (5/6 affected corneas). Systemic corticosteroids had been discontinued in all patients. Two recurrences occurred 13 and 53 months after the first rituximab infusion and where successfully treated with a new infusion. No rituximab-related adverse events were reported. Conclusions Rituximab was effective in the management of severe Moorens ulcers and could be an alternative to cyclophosphamide. Additional studies should assess the role of this biotherapy in the management of immunological corneal ulcer.