G. Brasseur

Long-term results of penetrating keratoplasty. A 10-year-plus retrospective study.

BackgroundThe aim of this study was to retrospectively analyse the outcome of a series of grafted patients over a period of more than 10 years and to determine their long-term survival probability.MethodsThe records of 89 patients who had 103 grafts performed in 97 eyes were analysed. Mean follow-up was 12.8 years (range 10–17 years). Life table analysis (Kaplan–Meier) was used to evaluate the graft survival of the total population and of different groups.ResultsEighteen out of 89 patients (20.2%) had died. At the last visit before their death, 10 of the 21 grafts in those patients were still clear. Graft survival rates after 1, 2, 5 and 10 years were 79%, 73%, 59% and 50%; the rate at the end of follow-up was 47%. Survival rate at the end of the study was 94.7% for keratoconus, 57.1% herpes keratitis, 33.3% for pseudophakic keratopathies, 28.5% for post-traumatic keratopathies and 11.1% for re-grafts. In the group of patients grafted for aphakic or pseudophakic keratopathy, 40% died during the study. In 45% of cases their grafts were clear at the time of death. Endothelial decompensation and definitive graft rejection were the main causes of failure.ConclusionsThe outcome of keratoplasty is progressively getting worse with time in pseudophakic or traumatic keratopathies whereas survival rates are still stable from 10 to 17 years in grafts performed after keratoconus or herpetic keratitis.

Predictive visual outcome after macula-off retinal detachment surgery using optical coherence tomography.

Purpose: To determine whether preoperative optical coherence tomography (OCT) is useful in predicting postoperative visual outcome for patients with primary macula-off rhegmatogenous retinal detachment (RD). Methods: This prospective study included 20 nonconsecutive eyes with macula-off RD and successful reattachment of the retina. Preoperative 5-mm OCT was performed through the center of the fovea. The relationship among preoperative OCT findings, main preoperative clinical variables, and final postoperative visual acuity was statistically analyzed. Results: Final postoperative visual acuity was negatively correlated with three preoperative OCT variables: height of RD at the central fovea (r =0.79; P < 0.001), distance from the central fovea to the nearest undetached retina (r = 0.75; P < 0.00051), and, to a lesser degree, extent of structural changes in the detached retina (r = 0.48; P = 0.03). Preoperative visual acuity was the only clinical variable statistically correlated with final postoperative visual acuity in this study (r = 0.55; P = 0.01). Using multivariate logistic regression analyses, the structure of the detached retina combined with the distance from the central fovea to the nearest undetached retina, as determined with OCT, was highly correlated with final postoperative visual acuity (r = 0.82; P < 0.000051). Conclusion: Preoperative macular analysis with OCT may help to predict visual outcome for patients with macula-off RD.

Results of surgery on macular holes that develop after rhegmatogenous retinal detachment

Aims: To evaluate the characterics and surgical prognosis of macular holes that develop after rhegmatogenous retinal detachment repair. Design: Retrospective, interventional, consecutive case series. Methods: The case records of nine patients who developed a new full-thickness macular hole after prior RD repair were reviewed over 6 years. Optical coherence tomography (OCT) confirmed these holes. They were offered surgical repair with a median follow-up of 13.3 months (1–63 months). Main outcomes included preoperative vitreo-macular status, OCT evaluation and postoperative visual acuity. Results: 1007 eyes underwent surgery for prior retinal detachment between August 1999 and September 2005. Nine eyes developed a full-thickness macular hole (prevalence 0.9%): five developed after scleral buckling surgery, one after pneumatic retinopexy and three after primary vitrectomy. The mean time to macular hole diagnosis after RD was 2.9 months (0.5–18). All patients underwent macular hole surgery by the same surgeon. At 1 month, macular hole repair was noticed in eight eyes. In this group, visual acuity at a median of 11.9 months of follow-up was 20/125 (20/400 – 20/63). Three eyes had an improvement of more than three Snellen lines. Conclusions: Macular holes developing after RD repair is a rare complication (less than 1%). Its physiopathological mechanisms are not well known. Conventional macular hole surgery including pars plana vitrectomy, inconstant internal limiting membrane delamination and long-acting gas tamponade seems to achieve to macular reattachment (89%). The visual outcome seems conditioned by the macular status noticed during the RD.

The interview with the donor's family before postmortem cornea procurement.

Purpose. Asking the family of a deceased patient to consider eye donation is one of the most difficult aspects of the donation process. The aim of this prospective study was to describe the content of interviews with the families of potential donors and to analyze their reactions to improve the process of eye donation. Methods. We consecutively met with 151 families of suitable corneal donors at the Rouen University Hospital. All interviews with donor families were analyzed using a preestablished questionnaire. Results. In only 17.9% of cases was the family aware of the potential donors last will. In 77.7% of these cases, the patient wished to donate. Procurement rate was 71.5%. This acceptance was mostly facilitated by the awareness and motivation of the hospital staff, the experience of the physician, and the 13.3-h period of time allowed after the donors death. The commitment on the part of the ophthalmologist to carry out optimal anatomical restoration was a very important point for 32% of families who accepted donation. Twenty-one percent of families asked for a delay for reflection. This delay helped to obtain a positive response in 72.7% of cases and even sometimes helped families to reconsider a previously negative position (14% of initial refusals). Conclusion. We demonstrate that a high positive response (71.5%) can be obtained from the donors family when a trained and motivated group manages the post-mortem cornea donation request.

In vivo confocal microscopic evaluation of corneal changes in chronic Stevens-Johnson syndrome and toxic epidermal necrolysis.

Purpose: To describe corneal changes visible on in vivo confocal microscopy, in patients with debilitating ocular sequelae because of toxic epidermal necrolysis (TEN) or Stevens-Johnson syndrome (SJS). Patients and Methods: Forty-one eyes of 25 consecutive patients suffering from chronic TEN or SJS were studied using in vivo confocal microscopy. Results: Severe dry eye syndrome with no associated limbal stem cell deficiency (25 eyes, 16 patients, 61%) was the most frequent clinical pattern. Limbal stem cell deficiency was noted in 16 eyes (12 patients, 39%). Three patients had asymmetric disease. Confocal microscopy showed a consistent change in the superficial epithelial cells in both clinical presentations. Patients with dry eye syndrome had frequent pathological nerve damages, and the presence of dendritic cells was prevalent (65%). Inflammatory cells were observed in a large number in 4 of the 12 patients presenting neovascularization of the cornea. Conclusions: The corneas of patients with chronic ocular sequelae linked to SJS and TEN present a number of abnormalities. In vivo confocal microscopy is a potentially useful tool for therapeutic indications and for follow-up of the debilitating chronic ocular problems associated with these diseases.

Detection and genotyping of the hepatitis C RNA in tear fluid from patients with chronic hepatitis C

Tear fluid from 51 patients with chronic hepatitis C virus (HCV) infection was analyzed for the presence of the hepatitis C RNA to assess the potential role of this fluid in virus transmission. HCV sequences were amplified from sera and tear fluids by nested polymerase chain reaction using primers from the 5′ non coding region of the virus genome. Positive samples were genotyped by the LiPATM procedure. HCV RNA was detected in 76.5% (39/51) of the sera and in 9.8% (5/51) of the tear fluid samples. The presence of the RNA in the tear fluid was independent of the severity of the hepatitis and of the viral load as measured by the branched DNATM assay. The genotypes of the tears and serum isolates were different for two patients. For another patient, the HCV RNA was positive in the tear sample but negative in the serum sample. These findings suggest that tear fluid may transmit HCV but the source of HCV RNA in this fluid needs to be better understood. J. Med. Virol. 51:231–233, 1997.

Intérêt des greffes de membranes amniotiques dans les pathologies oculaires de surface

La greffe de membrane amniotique est une technique desormais adoptee par tous dans la prise en charge des pathologies de la surface oculaire. Suivant les indications, la membrane amniotique est utilisee en greffe ou en patch. Dans le premier cas, la membrane amniotique sert de substrat a la repousse epitheliale deficiente et le chirurgien vise l’integration de la membrane amniotique. Sa membrane basale permet en effet de renforcer l’adhesion et la differentiation des cellules epitheliales de la cornee, de faciliter leur migration et de prevenir leur apoptose. Dans le deuxieme cas (patch), la membrane amniotique est suturee epithelium vers le bas de facon a delivrer les facteurs biologiques dont elle est impregnee en concentration maximale : elle recouvre la cornee pathologique en jouant a la fois un role de pansement biologique et egalement un role antalgique. Les meilleures indications des greffes de membrane amniotique sont les brulures chimiques au stade aigu et les ulceres corneens trophiques refractaires a tout traitement medical. Lorsque ces derniers sont perforants ou preperforants, la greffe amniotique est realisee au mieux en multicouches de facon a permettre la restauration d’une certaine epaisseur corneenne. En cas de deficit limbique avere, la membrane amniotique peut etre un complement interessant aux techniques de greffes de cellules souches limbiques desormais necessaires. A l’avenir, la membrane amniotique sera le support indispensable des expansions de cellules souches cultivees. La greffe de membrane amniotique peut egalement etre proposee pour reconstruire la conjonctive lors de la chirurgie d’exerese des symblepharons ou des tumeurs conjonctivales. Son utilisation isolee n’est alors limitee qu’aux pathologies peu inflammatoires et sans fibrose extensive.

Impact of new lamellar techniques of keratoplasty on eye bank activity

BackgroundDeep anterior lamellar keratoplasty (DALK) has become an increasingly popular alternative to penetrating keratoplasty in patients with stromal corneal pathologies. The main advantages of DALK are: prevention of long-term endothelial loss, elimination of allograft reaction and short topical steroid treatment with lower risks of glaucoma, cataract and infection. Because this technique enables surgeons to use corneal grafts with low endothelial density, the aim of this paper was to determine whether this type of innovation has had a significant impact on eye bank activity.MethodsWe reviewed our corneal graft activity over a 40-month period and assessed the proportion of deep lamellar and penetrating keratoplasties. During the same period, we also evaluated our eye bank activity and recorded the utilisation of grafts with endothelium abnormalities, which were only suitable for lamellar techniques.ResultsDeep lamellar keratoplasty represented 29.8% (85 out of 285) of corneal transplantations. Forty-eight percent of all corneas stored at the local eye bank were unsuitable for penetrating keratoplasty; 36.6% of those were not suitable for endothelial deficiencies. Among these, 72.7% were used for DALK and 27.3% were rejected. This permitted a 24.5% increase in corneal grafting activity. In contrast, Descemet’s membrane was removed at the time of surgery in 12% of corneas with healthy endothelium, which was used for deep lamellar keratoplasty.ConclusionsDeep anterior lamellar keratoplasty development and close collaboration between eye banks and surgeons can induce a significant increase in corneal grafting. This could be a partial solution in countries confronted with corneal graft shortages.

Prise en charge chirurgicale des perforations cornéennes non traumatiques : étude rétrospective sur 8 ans

But de l’etude La prise en charge des perforations corneennes non traumatiques reste difficile. Nous avons mene une etude retrospective afin d’en recenser les etiologies et de rapporter l’efficacite des differentes techniques chirurgicales. Patients et methodes Notre serie comprend 56 patients hospitalises entre 1997 et 2004 pour une perforation corneenne non traumatique. L’âge moyen des patients etait de 69 ans (16 a 95 ans), le suivi moyen de 20,5 mois (6 a 96 mois). Resultats Les causes de perforation corneenne ont ete un ulcere trophique dans 24 cas (43 %), un ulcere inflammatoire peripherique dans 10 cas (18 %), une perforation corneenne sur syndrome sec dans 6 cas (11 %), un abces infectieux perforant dans 7 cas (13 %). Tous les patients ont eu un traitement medical specifique adapte avant d’envisager la chirurgie. En premiere intention, la colle cyanoacrylate a ete utilisee dans 14 cas (50 % de succes anatomique), une greffe amniotique en multicouches dans 23 cas (100 % de succes anatomique), un recouvrement conjonctival dans 6 cas, une greffe lamellaire peripherique dans 3 cas (33 % de succes anatomique), une greffe transfixiante « a chaud » dans 13 cas (31 % de succes anatomique) et un patient a du etre eviscere. Plusieurs interventions ont ete necessaires dans 16 cas (28 %), neuf patients ayant au final un recouvrement conjonctival. L’integrite du globe a pu etre maintenue dans 91 % des cas et 32 % des yeux ont recupere une acuite visuelle chiffrable entre 1/20 e et 4/10 e . Conclusion Les perforations corneennes non traumatiques sont souvent de mauvais pronostic visuel malgre une prise en charge rapide. La greffe amniotique en multicouches est un outil chirurgical tres efficace lorsque la perforation est d’origine trophique. Nous recommandons la realisation d’un recouvrement conjonctival en cas de recidive de la perforation.

Sub-Tenon infiltration or classical analgesic drugs to relieve postoperative pain.

Background: In a prospective randomized double‐blind study, the analgesic effect produced by sub‐Tenon infiltration was compared with classic analgesic drugs in patients scheduled for posterior segment surgery under general anaesthesia.