Hideaki Yokogawa

Descemet stripping with automated endothelial keratoplasty for bullous keratopathies secondary to argon laser iridotomy--preliminary results and usefulness of double-glide donor insertion technique.

Purpose: Manipulation of the endothelial donor lamella in the anterior chamber during Descemet stripping with automated endothelial keratoplasty (DSAEK) is often difficult, especially in cases with bullous keratopathies (BK) secondary to argon laser iridotomy (ALI). We developed a novel nonfolding donor insertion technique using a Busin glide and an intraocular lens (IOL) sheet glide and evaluated post-DSAEK outcomes for ALI-induced BK using several insertion techniques. Methods: Fourteen patients (mean age, 74.2 ± 4.9 years) with ALI-induced BK underwent DSAEK; simultaneous cataract surgery was performed in 12 patients. Donor insertions were done by taco-folding (n = 4), spatula-assisted (n = 3), Busin glide-assisted (n = 2), and Busin glide/IOL glide-assisted methods (n = 5). Endothelial cell counts, postoperative visual acuity, induced astigmatism, and complications were examined over a mean follow-up period of 228.3 ± 132.2 days (range 58-458 days). Results: In 1 case, DSAEK was converted to penetrating keratoplasty because of difficulties in donor insertion by the taco-folding method, resulting in vitreous prolapse. Overall, mean postoperative endothelial cell count was 1654.2 ± 532.3 cells/mm2 (range 853-2610 cells/mm2), a 44.9% reduction compared with donor counts (mean 3003.3 ± 425.5 cells/mm2). All patients reached acuity >20/40, with 3 (23.1%) reaching 20/20. Mean induced astigmatism in measurable cases was 0.53D ± 0.38D. Although nonsignificant due to the small sample size, use of Busin glide with (37.9%) or without IOL glide (37.0%) tended to cause less endothelial damage than taco-folding (49.0%) or pull-through with spatula (44.2%) at 3 months postoperatively. Conclusions: DSAEK is effective in eyes with ALI-induced BK. Our results suggest that insertion with a Busin glide is reliable and associated with less endothelial cell damage than the conventional taco-folding technique. Simultaneous use of IOL glide (Kobayashi double-glide method) to help prevent iris prolapse is our preferred insertion method for narrow-angle eyes.

Non-Descemet Stripping Automated Endothelial Keratoplasty for Endothelial Dysfunction Secondary to Argon Laser Iridotomy

PURPOSE To report clinical outcomes of non-Descemet stripping automated endothelial keratoplasty (nDSAEK) as treatment of endothelial dysfunction secondary to argon laser iridotomy (ALI). DESIGN Single-center, prospective, noncomparative, interventional case series. METHODS Six eyes of six patients (two men, four women; mean age, 74.5 years) with bullous keratopathies secondary to ALI were treated with endothelial keratoplasty without recipient Descemet stripping. The donor endothelial lamella was inserted using a pull-through technique using a Busin glide with intraocular lens glide (i.e., Kobayashi double-glide technique). Best-corrected visual acuity (BCVA), astigmatism, and donor central endothelial cell density (ECD) were recorded before surgery and at six months after surgery. Intraoperative and postoperative complications also were recorded. Main outcome measures were preoperative and postoperative central ECD, with calculation of cell loss rate. BCVA, induced astigmatism, and complications also were evaluated. RESULTS All patients reached more than 20/32 BCVA, with two (33.3%) reaching 20/20. Mean induced astigmatism in measurable cases was 0.85 +/- 0.49 diopters. The average and standard deviation ECD at six months were 2390.5 +/- 522.4 cells/mm(2) (range, 1589 to 2898 cells/mm(2)), representing a mean cell loss from preoperative donor cell measurements of 25.8% +/- 14.7%. Complications included one case of donor dislocation requiring rebubbling (16.7%) and one case of subclinical endothelial rejection (16.7%). CONCLUSIONS This modified endothelial keratoplasty technique (nDSAEK and double-glide technique) for treatment of endothelial dysfunction secondary to ALI produced excellent clinical outcomes such as reduced endothelial cell loss, good visual acuity, and minimal induced astigmatism.

In vivo and ex vivo laser confocal microscopy findings in patients with early-stage acanthamoeba keratitis.

Objective: This study included in vivo and ex vivo investigations of patients with early-stage Acanthamoeba keratitis by using new-generation laser confocal microscopy (Heidelberg Retina Tomograph 2 Rostock Cornea Module [HRT 2-RCM]). Methods: Three patients (2 men and 1 woman; mean age, 22.0 years) with early-stage Acanthamoeba keratitis diagnosed by direct examination (Parker ink-potassium hydroxide stain), culture from corneal epithelial scrapings, or both methods were enrolled in this study. All patients were examined by slit-lamp biomicroscopy. The area of the affected cornea was examined by HRT 2-RCM. Selected images of in vivo corneal layers and ex vivo cultured microorganisms were evaluated qualitatively for shape and degree of light reflection of the corneal structural changes or Acanthamoeba cysts. In addition, cultured Acanthamoeba were examined ex vivo by HRT 2-RCM. Results: In vivo laser confocal microscopy showed highly reflective round-shaped, high-contrast Acanthamoeba cysts (10-20 μm in diameter) in the corneal epithelium in all cases, leading to rapid confirmation of the clinical diagnosis. In all culture samples of Acanthamoeba, ex vivo laser confocal microscopy showed highly reflective round- or stellate-shaped high-contrast particles (10-20 μm in diameter). Conclusions: In vivo laser confocal microscopy enables rapid and noninvasive diagnosis of early-stage Acanthamoeba keratitis with high resolution. In addition, ex vivo laser confocal images of Acanthamoeba cysts may be helpful when similar structures are identified and have to be interpreted under in vivo conditions.

Clinical Significance of Owl Eye Morphologic Features by In Vivo Laser Confocal Microscopy in Patients With Cytomegalovirus Corneal Endotheliitis

OBJECTIVE To demonstrate the clinical significance of owl eye morphologic features observed by in vivo laser confocal microscopy in patients with cytomegalovirus (CMV) corneal endotheliitis. DESIGN Observational case series. METHODS participants: Six eyes of 6 patients (6 men; mean age, 73.3 years) with cytomegalovirus corneal endotheliitis diagnosed by clinical manifestations together with polymerase chain reaction from aqueous humor samples. intervention: All patients were examined by slit-lamp biomicroscopy and in vivo laser confocal microscopy. main outcome measures: Clinical manifestations were summarized by reviewing medical records. Selected confocal images of corneal layers were evaluated qualitatively for shape and degree of light reflection of abnormal cells and deposits. RESULTS All patients had long histories of anterior uveitis with intraocular pressure elevation, corneal edema with keratic precipitates, and decrease of endothelial cell densities. Coin-shaped lesions were observed by slit lamp only in 1 patient at the first visit and in 2 additional patients at subsequent follow-up. In all patients, confocal microscopy demonstrated reduced subepithelial nerves, subepithelial opacity, increased reflectivity of keratocytes, highly reflective dots, and needle-shaped bodies. Owl eye morphologic features were observed consistently in all patients at the initial visit, and highly reflective round bodies were detected in 5 patients; most notably, these confocal features were reversible after resolution of endotheliitis. CONCLUSIONS Owl eye morphologic features and highly reflective round bodies observed by confocal microscopy may be useful as an adjunct for the noninvasive diagnosis of cytomegalovirus corneal endotheliitis. Reversibility of these features after resolution of endotheliitis may be useful for monitoring the therapeutic effects without multiple anterior chamber tap.

In Vivo Laser Confocal Microscopy after Non–Descemet's Stripping Automated Endothelial Keratoplasty

OBJECTIVE To investigate in vivo corneal changes in patients with bullous keratopathy who underwent non-Descemets stripping automated endothelial keratoplasty (nDSAEK) with the use of laser confocal microscopy. DESIGN Single-center, prospective clinical study. PARTICIPANTS Ten eyes (10 patients; 3 men and 7 women; mean age, 73.5+/-6.6 years [mean+/-standard deviation]) with bullous keratopathy were evaluated in this study. TESTING In vivo laser confocal microscopy was performed before and 1, 3, and 6 months after nDSAEK. MAIN OUTCOME MEASURES Selected confocal images of corneal layers were evaluated qualitatively and quantitatively for degree of haze and density of deposits. RESULTS Before surgery, the following were observed in all patients: corneal epithelial edema, subepithelial haze, keratocytes in a honeycomb pattern, and tiny needle-shaped materials in the stroma. After nDSAEK, subepithelial haze, donor-recipient interface haze, and interface particles were observed in all measurable cases; postoperative haze, interface particles, and needle-shaped materials decreased statistically significantly (P<0.05) over the course of follow-up. In addition, hyperreflective giant interface particles were observed after nDSAEK in all patients. CONCLUSIONS In vivo laser confocal microscopy can identify subclinical corneal abnormalities after nDSAEK such as subepithelial haze, host-recipient interface haze, host stromal needle-shaped materials, and host-recipient interface particles with characteristic giant particles. Further studies with this technology in a large number of patients and long-term follow-up are needed to understand fully the long-term corneal stromal changes after nDSAEK.

Subfoveal Choroidal Thickness Change Following Segmental Scleral Buckling for Rhegmatogenous Retinal Detachment

PURPOSE To report the morphologic changes of the subfoveal choroidal thickness using spectral-domain optical coherence tomography following segmental scleral buckling. DESIGN Retrospective, observational case series. METHODS The study included 21 eyes of 20 patients who underwent segmental scleral buckling for the treatment of rhegmatogenous retinal detachment. All patients underwent the measurements of the subfoveal choroidal thickness preoperatively and 1 week, 1 month, and 3 months after the surgery. The changes in choroidal thickness, 4 mm from the fovea, before and 1 week after surgery were analyzed in the buckled and unbuckled side. RESULTS The preoperative mean subfoveal choroidal thickness of operated eyes was 239.2 ± 91.0 μm. The postoperative mean subfoveal choroidal thicknesses of operated eyes at 1 week, 1 month, and 3 months were 267.6 ± 96.8 μm, 250.6 ± 95.8 μm, and 239.4 ± 95.6 μm, respectively. There were significant differences between preoperative subfoveal choroidal thickness and 1-week-postoperative and 1-month-postoperative subfoveal choroidal thicknesses (P < .01, P = .03, ANOVA), and there was no significant difference between subfoveal choroidal thicknesses preoperatively and 3 months postoperatively (P > .99, ANOVA). The changes in choroidal thickness of the buckled and unbuckled side preoperatively and 1 week postoperatively were not significantly different (n = 8, P = .589, 2-way ANOVA). CONCLUSION The subfoveal choroidal thickness may change temporarily following segmental scleral buckling surgery. This may be the result of reversible subclinical microcirculatory dysfunction of the choroid.

Mapping of normal corneal K-structures by in vivo laser confocal microscopy.

Purpose: To produce 2-dimensional reconstruction maps of normal human corneal fibrous structures beneath the Bowman layer (K-structures) by in vivo laser confocal microscopy and to show association of structures with the anterior corneal mosaic (ACM). Methods: Central corneal regions of 3 healthy volunteers were scanned. Acquired images of K-structures for each eye were arranged and mapped into a subconfluent montage. For each subject, electrical tracings of K-structures were superimposed on a slit-lamp photograph of the ACM produced by rubbing the eyelid. Results: A mean of 677 ± 211 images of K-structures were obtained for each eye. Mean dimensions of the mapped areas were 5.88 ± 0.50 (horizontal) and 3.51 ± 1.37 mm (vertical). In all subjects, K-structures formed a netlike pattern (mean area, 0.082 ± 0.051 mm2), and electrical tracings had good concordance with the ACM. Conclusions: This is the first study, to our knowledge, to elucidate the overall distribution of K-structures in normal human corneas. The netlike pattern of K-structures corresponded well with ACM pattern. These results support the hypothesis that the K-structures are the anterior collagen fiber bundles running at the posterior surface of the Bowman layer and thus are the structural basis for ACM formation.

In Vivo Laser Confocal Microscopy after Descemet's Membrane Endothelial Keratoplasty

OBJECTIVE To investigate the in vivo corneal changes in patients with bullous keratopathy who underwent Descemets membrane endothelial keratoplasty (DMEK) with the use of in vivo laser confocal microscopy. DESIGN Single-center, retrospective clinical study. PARTICIPANTS Five eyes of 4 patients (3 men, 1 women; mean age, 61.3 ± 9.6 years) with bullous keratopathy who had undergone successful DMEK were enrolled in this study. TESTING In vivo laser confocal microscopy was performed before and 1, 3, and 6 months after DMEK. MAIN OUTCOME MEASURES Selected confocal images of corneal layers were evaluated qualitatively and quantitatively for the degree of haze and the density of deposits. Subepithelial haze, donor-recipient interface haze, donor-recipient interface particles, and host stromal needle-shaped materials were graded on a scale of 4 categories (grade 0 = none, grade 1 = mild, grade 2 = moderate, grade 3 = severe) at each time point. Time trends of the outcomes were graphically displayed and evaluated with Mantel-Haenszel trend test. RESULTS The following were observed preoperatively in all patients: slight corneal epithelial edema, moderate subepithelial haze, keratocytes in a honeycomb pattern, and tiny needle-shaped materials in the stroma. After DMEK, moderate subepithelial haze persisted during the follow-up period. Needle-shaped materials had a tendency to decrease after DMEK. Most notably, donor-recipient interface haze and donor-recipient interface particles were barely noticeable after DMEK as early as 1 month postoperatively. CONCLUSIONS In vivo laser confocal microscopy can identify subclinical corneal abnormalities after DMEK, such as subepithelial haze, host stromal needle-shaped materials, and minimum donor-recipient interface haze/particles. These abnormalities seemed subtle compared with Descemet stripping automated endothelial keratoplasty; this may explain the superior postoperative visual acuity after DMEK. Further studies with this technology in a large number of patients and long-term follow-up are needed to fully understand the long-term corneal changes after DMEK. FINANCIAL DISCLOSURE(S) The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Evaluation of internationally shipped prestripped donor tissue for descemet membrane endothelial keratoplasty by vital dye staining.

Purpose: The aim of this study was to evaluate endothelial cell damage of internationally shipped prestripped donor tissue for Descemet membrane endothelial keratoplasty (DMEK) using vital dye staining. Methods: Six internationally shipped prestripped DMEK donors were stained with trypan blue and were subsequently photographed before they were cut with a trephine. Quantitative analysis assessment of endothelial damage of the donor graft area (8.0 mm in diameter) was performed using Adobe Photoshop CS6 Extended software. Seven internationally shipped precut Descemet stripping automated endothelial keratoplasty (DSAEK) donors were used as controls. Results: No statistical differences were noted between prestripped DMEK donors and precut DSAEK donors in mean donor age (67.7 vs. 56.4 years, P = 0.222), mean donor endothelial cell density (2687.3 vs. 2894.6 cells, P = 0.353), and death-to-preservation time (405.3 vs. 558.4 minutes, P = 0.173). However, the mean time of death-to-experiment time in DMEK donors was significantly longer than that of DSAEK donors (8.7 vs. 6.6 days, P = 0.031). Mean endothelial cell damage of prestripped DMEK donors was as low as 0.3%. However, DMEK donor endothelial damage (0.3%) was significantly higher compared with that of precut DSAEK donor tissue (0.01%, P = 0.029). Conclusions: Although endothelial damage of internationally shipped prestripped donor tissue for DMEK was higher than that of precut DSAEK donor, it was extremely low. Further evaluation using another vital dye and clinical studies may be needed to confirm this study.

Surgical therapies for corneal perforations: 10 years of cases in a tertiary referral hospital

Purpose To report surgical therapies for corneal perforations in a tertiary referral hospital. Methods Thirty-one eyes of 31 patients (aged 62.4±18.3 years) with surgically treated corneal perforations from January 2002 to July 2013 were included in this study. Demographic data such as cause of corneal perforation, surgical procedures, and visual outcomes were retrospectively analyzed. Results The causes of corneal perforation (n=31) were divided into infectious (n=8, 26%) and noninfectious (n=23, 74%) categories. Infectious causes included fungal ulcer, herpetic stromal necrotizing keratitis, and bacterial ulcer. The causes of noninfectious keratopathy included corneal melting after removal of a metal foreign body, severe dry eye, lagophthalmos, canaliculitis, the oral anticancer drug S-1, keratoconus, rheumatoid arthritis, neurotrophic ulcer, atopic keratoconjunctivitis, and unknown causes. Initial surgical procedures included central large corneal graft (n=17), small corneal graft (n=7), and amniotic membrane transplantation (n=7). In two cases the perforation could not be sealed during the first surgical treatment and required subsequent procedures. All infectious keratitis required central large penetrating keratoplasty to obtain anatomical cure. In contrast, several surgical options were used for the treatment of noninfectious keratitis. After surgical treatment, anatomical cure was obtained in all cases. Mean postoperative best corrected visual acuity was better at 6 months (logMAR 1.3) than preoperatively (logMAR 1.8). Conclusion Surgical therapies for corneal perforations in our hospital included central large lamellar/penetrating keratoplasty, small peripheral patch graft, and amniotic membrane transplantation. All treatments were effective. Corneal perforation due to the oral anticancer drug S-1 is newly reported.