Eliya Levinger

Retrospective contralateral study comparing descemet stripping automated endothelial keratoplasty with penetrating keratoplasty.

Purpose: To compare the visual outcomes and complications rate after penetrating keratoplasty (PKP) and Descemet stripping automated endothelial keratoplasty (DSAEK), in the fellow eye of the same subjects, and to evaluate the patients perspective on these operations. Methods: A retrospective cohort study was undertaken in the Cornea Clinic at the Toronto Western Hospital. We reviewed the records of 12 patients (24 eyes) who underwent PKP in one eye and DSAEK surgery in their fellow eye. Patients satisfaction for both procedures was evaluated using a subjective questionnaire. These techniques were compared for intraoperative and postoperative complications and visual and refractive outcomes including contrast acuity, contrast threshold, and high-order ocular aberrations (HOA). Results: All the patients in this study preferred the DSAEK operation. They reported faster recovery time [1.5 week in the DSAEK vs 5.3 weeks in the PKP operation (P = 0.01)], significantly less pain, and better visual outcomes with the DSAEK operation. Uncorrected visual acuity and best-corrected visual acuity were significantly better in the DSAEK operated eyes. The DSAEK surgery was associated with significantly less astigmatism (P = 0.0003) and ametropia. Contrast acuity was significantly better in the eye that underwent DSAEK procedure (P < 0.05), whereas contrast threshold was better in the PKP eye. The PKP operated eyes demonstrated increased level of HOA. Conclusions: Patients preferred the DSAEK operation compared with PKP. Better uncorrected visual acuity, best-corrected visual acuity, and contrast acuity together with avoidance of surgery-induced astigmatism and HOA are the main benefits of the DSAEK technique.

Femtosecond laser versus manual dissection for top hat penetrating keratoplasty

Aim: To compare the outcomes of IntraLase-enabled top hat penetrating keratoplasty (IEK) versus retrospective results of manual top hat penetrating keratoplasty (TH-PKP) and conventional PKP. Patients/methods: This non-randomised prospective study included 94 eyes: 23 eyes underwent IEK, 36 TH-PKP and 35 conventional PKP. Preoperative and postoperative manifest refraction, uncorrected and best-spectacle corrected visual acuity (BSCVA), high-order ocular aberrations (HOA), endothelial cell counts and complications were analysed. Results: At 12 months of follow-up, the mean log MAR BSCVA was 0.32 (SD 0.31) in the IEK group, 0.53 (0.36) in the TH PKP group (p = 0.03) and 0.39 (0.30) in the conventional PKP group (p = 0.4). The mean spherical equivalent was similar between the groups and was less than −2.2 dioptres. The mean cylinder was similar in the IEK and conventional PKP group (3.6 (1.9) dioptres and 4.1 (1.8) dioptres, respectively), and was significantly lower than the TH-PKP group (5.1 (3.2) dioptres, p = 0.04). The complications rate and high-order ocular aberrations were similar between the three groups studied. The mean endothelial cell loss was significantly lower at 12 months of follow-up in the IEK and the TH-PKP groups versus conventional PKP (32.4% and 22.3% vs 40.8%, respectively) (p = 0.05). The mean time to suture removal was 4.1 (1.2) months in the IEK group and 3.9 (1.5) months in the TH-PKP group versus 9.7 (1.1) months in the conventional PKP group (p<0.0001). Conclusions: IEK is a safe and stable procedure. It results in higher endothelial counts and faster suture removal in comparison with the conventional PKP, and has less astigmatism and better BSCVA in comparison with the manual TH-PKP.

Combined use of superficial keratectomy and subconjunctival bevacizumab injection for corneal neovascularization.

Purpose: To report the effect of superficial keratectomy combined with subconjunctival bevacizumab injection in 2 cases of corneal neovascularization (NV). Methods: An interventional case series was undertaken on 2 patients with corneal NV: 1 due to sclerokeratitis secondary to rheumatoid arthritis and the other due to Terrien marginal degeneration. Both patients underwent superficial keratectomy combined with subconjunctival bevacizumab injection (2.5 mg/0.1 mL). Results: Corneal NV regressed with the surgical removal and showed no signs of recurrence after 3 months of follow-up. Both patients reported dramatic subjective improvement in their vision within 1-2 weeks. Best corrected visual acuity improved in 1 patient. Conclusion: The combination of superficial keratectomy with subconjunctival injection of bevacizumab may offer a new strategy for the treatment of superficial corneal NV.

Topical treatment with 1% cyclosporine for subepithelial infiltrates secondary to adenoviral keratoconjunctivitis.

Purpose: To evaluate the treatment with topical 1% cyclosporine A (CsA) in patients with subepithelial corneal infiltrates (SEIs). Methods: We retrospectively reviewed the records of 9 patients (12 eyes) before and after the treatment with CsA 1% eyedrops twice daily. All patients had been treated with topical corticosteroids previously without improvement or had to stop the medication secondary to intraocular pressure elevation. The objective data recorded included best-corrected Snellen visual acuity, intraocular pressure, number of medications in use, and evaluation of severity of SEIs (improved, stable, or worse). For their subjective evaluation, patients were asked to complete a questionnaire based on the last follow-up visit. Results: Five males (56%) and 4 females (44%), mean age of 47 ± 13 years, were included. Mean follow-up on CsA was 13 ± 7 months. The mean best-corrected Snellen visual acuity (logarithm of the minimum angle of resolution) before and after treatment was 0.42 ± 0.40 and 21 ± 0.28, respectively, with no statistically significant improvement. There was statistically significant reduction in the number of medications before and after treatment from 1.88 ± 1.05 to 1.22 ± 0.44, respectively (P = 0.049). Six patients (66%) showed clinical improvement, and 3 (34%) were stable during the treatment period. Patients reported statistically significant reduction in the severity of symptoms before and after the treatment. Most of the patients reported no foreign body sensation, glare, or other side effects with topical CsA treatment. Overall, patients noted an improvement in vision and satisfaction with CsA treatment. Conclusions: Topical CsA 1% is a safe and effective alternative treatment in patients with SEIs who do not respond to other treatment modalities or have unwanted side effects from topical steroids.

Posterior lamellar keratoplasty--comparison of deep lamellar endothelial keratoplasty and Descemet stripping automated endothelial keratoplasty in the same patients: a patient's perspective.

Aim: To evaluate patients’ perspectives on endothelial keratoplasty and to compare the outcomes of deep lamellar endothelial keratoplasty (DLEK) and Descemet stripping automated endothelial keratoplasty (DSAEK), performed in the same patients. Methods: A fellow eye, comparative retrospective case series. The records of 14 patients (28 eyes) who underwent DLEK in one eye and DSAEK surgery in their fellow eye between 2003 and 2007 were reviewed. Two patients were excluded from the study. Both these techniques were compared for intra- and postoperative complications, visual and refractive outcomes including higher-order ocular aberrations (HOA). Patient satisfaction for both procedures was prospectively evaluated using a subjective questionnaire. Results: Nine (75%) of the 12 patients perceived better vision in the DSAEK operated eye. Eight (66.6%) of the patients reported faster recovery following DSAEK. Ten (83%) of them preferred the outcomes of the DSAEK surgery. The intra- and postoperative complications were comparable between both procedures. There was no significant difference in visual outcomes between the procedures. However, the DLEK procedure was associated with a significantly higher degree (p<0.05) of HOA. Endothelial cell loss was similar following DLEK and DSAEK. Conclusions: We conclude that most patients prefer the DSAEK operation, although there are no differences in visual outcomes between DLEK and DSAEK. Avoidance of surgery-induced hyperopia and HOA is the main benefit of the DSAEK technique.

Outcome of "mushroom" pattern femtosecond laser-assisted keratoplasty versus conventional penetrating keratoplasty in patients with keratoconus.

Purpose: The aim of this study was to compare the outcomes of “mushroom” femtosecond laser–enabled keratoplasty (M-FLEK) with those of conventional penetrating keratoplasty (PKP) in eyes with keratoconus. The femtosecond laser–enabled “mushroom” pattern keratoplasty technique results in less postoperative astigmatism and higher endothelial cell counts compared with conventional PKP in patients with keratoconus. Methods: This was a nonrandomized retrospective, single private center clinical study. Between March 2010 and April 2012, 26 eyes underwent M-FLEK and 33 eyes underwent conventional PKP. Data on preoperative and postoperative manifest refraction, uncorrected visual acuity and best-corrected visual acuity (BCVA), endothelial cell counts, vector analysis, and complications were retrieved and analyzed. Results: At 12 months of follow-up, the mean logMAR BCVA was 0.31 ± 0.55 in the M-FLEK group and 0.32 ± 0.21 in the PKP group (P = 0.91). The mean spherical equivalent was similar between the groups. The mean manifest cylinder was significantly lower in the M-FLEK group (−2.84 ± 1.08 diopters) than in the PKP group (−3.93 ± 2.26 diopters; P = 0.03). There was a smaller mean endothelial cell loss in the M-FLEK group compared with the PKP group (32.1% vs 38.7%, respectively, P = 0.17) 1 year postoperatively. The complication rates were similar for both groups. Conclusions: M-FLEK appears to be a safe procedure that results in less astigmatism and a trend toward higher endothelial cell counts compared with conventional PKP, with similar postoperative BCVA.

IntraLase-enabled astigmatic keratotomy for correction of astigmatism after Descemet stripping automated endothelial keratoplasty: a case report.

Purpose: The purpose of this study was to report on the treatment of high astigmatism after Descemet stripping automated endothelial keratoplasty with IntraLase (IntraLase, Inc., Irvine, CA) -enabled astigmatic keratotomy (IEAK). Methods: A 85-year-old patient with pseudophakic bullous keratopathy underwent an intraocular lens exchange and Descemet stripping automated endothelial keratoplasty surgery on his left eye. Four months after surgery, high astigmatism was treated with IEAK. Results: Preoperative uncorrected visual acuity was 20/300 and best spectacle-corrected visual acuity was 20/100 with a refraction of -4.00 + 5.75 × 150. Seven months post-IEAK, uncorrected visual acuity was improved to 20/60 and best spectacle-corrected visual acuity 20/40-2 with a refraction of -1.50 + 2.75 × 100. Conclusion: IEAK, as presented here, can be used for the correction of high post-Descemet stripping automated endothelial keratoplasty astigmatism.

Air-pulse corneal applanation signal curve parameters for characterization of astigmatic corneas.

Purpose: The aim of this study was to test the 42 parameters of the ocular response analyzer for distinguishing between the biomechanical properties of emmetropic eyes with normal topography and eyes with moderate-to-high with-the-rule astigmatism (WTA) and against-the-rule astigmatism (ATA) that have symmetric bowtie topography. Methods: This retrospective case series study included 37 patients (37 studied eyes) with WTA astigmatism and 35 patients (35 studied eyes) with ATA astigmatism. The control group consisted of 70 patients with emmetropia (70 studied eyes) with normal topography. We first tested correlations of the parameters that describe the applanation curve during ocular response analyzer measurements with the maximum keratometry values and the corneal thickness in all 3 groups. We then evaluated the significant parameters among them in search of any group differences in the biomechanical properties of the cornea. Results: Fifteen parameters correlated with Kmax reading values or corneal thickness values. The correlation coefficients (r) were low. The best correlated parameters were p1area, p2area, h1, dive1, p2area1, h11, h2, and h21. The ATA group had the highest number of parameters (n = 6) with significant differences compared with the control group. Only p2area was predictive for ATA. In contrast, the WTA group had only 1 parameter (p2area1) that was found to be significantly different compared with the control group. Conclusions: Some of the new waveform parameters can distinguish between patients with ATA and WTA and normal topography patterns and may delineate the differences in biomechanical properties between these groups that may predict the risk of corneal ectasia after laser in situ keratomileusis.