Jeffrey Goshe

Graft Dislocation and Hypotony after Descemet's Stripping Automated Endothelial Keratoplasty in Patients with Previous Glaucoma Surgery

PURPOSE To determine if patients with prior glaucoma surgery experience higher rates of postoperative graft dislocation after Descemets stripping automated endothelial keratoplasty (DSAEK) and to determine if postoperative hypotony may be a risk factor in these patients. DESIGN Retrospective, comparative analysis of an interventional case series. PARTICIPANTS Eight hundred fifty-four eyes (67 eyes with prior glaucoma surgery and 787 controls) from 582 patients who underwent DSAEK at 1 institution between January 2005 and April 2011. METHODS Groups were compared with regard to preoperative, intraoperative, and postoperative parameters. Continuous variables were compared using the independent samples t test or Mann-Whitney U test. Categorical variables were compared using the chi-square test or Fisher exact test. MAIN OUTCOME MEASURES Frequencies of postoperative graft dislocation and postoperative hypotony. RESULTS Study eyes before surgery differed from control eyes with regard to corneal thickness (768 vs. 655 μm; P<0.001) and intraocular pressure (13 vs. 16 mmHg; P<0.001). Postoperative graft dislocation occurred significantly more frequently in study eyes compared with control eyes (9% vs. 2%; P = 0.008). Among eyes in which dislocation occurred, postoperative hypotony was present in 5 study eyes (83%) and 0 control eyes. CONCLUSIONS Previous glaucoma surgery was associated with a significantly increased rate of graft dislocation compared with control eyes. Dislocation was related strongly to postoperative hypotony in eyes with prior glaucoma surgery. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found after the references.

Association between transient interface fluid on intraoperative OCT and textural interface opacity after DSAEK surgery in the PIONEER study.

Purpose: The aim of this study was to examine the association between transient interface fluid (TIF) and textural interface opacity (TIO) after Descemet stripping automated endothelial keratoplasty (DSAEK) surgery using intraoperative optical coherence tomography (iOCT) in the PIONEER (Prospective Intraoperative and Perioperative Ophthalmic ImagiNg with Optical CoherEncE TomogRaphy) study. Methods: All consecutive eyes that underwent DSAEK between October 2011 and September 2013 from the PIONEER intraoperative and perioperative OCT study were included. iOCT images were captured after lenticule apposition with complete air fill and after air-fluid exchange. Postoperative day 1 OCT images were obtained. Outcome variables included the presence of TIO at the graft–host junction and the presence of intraoperative and postoperative interface fluid on OCT. Results: Seventy-six eyes from 69 patients who underwent DSAEK with iOCT were included. The mean age of the patients was 71 years (range 31–90). The 2 most common indications for surgery were Fuchs dystrophy (63%) and pseudophakic bullous keratopathy (24%). In 18 of 76 (23.7%) eyes, TIF was visible on iOCT post air-fluid exchange. Of these eyes, 14 developed TIO. TIO was observed in 18 of 76 (23.7%) eyes. TIF on iOCT was associated with a significantly higher rate of postoperative TIO (odds ratio = 47.25; P < 0.0001). Sixteen of the 18 eyes that had TIF on iOCT had had resolution on the postoperative day 1 OCT. There was no significant difference in the mean graft thickness between eyes with TIF on iOCT and those without (P = 0.58). Conclusions: Eyes with TIF on iOCT are more likely to develop TIO in the postoperative period. It is believed that the process of gap closure results in TIO, possibly secondary to precipitated solutes, retained viscoelastic, or lamellar irregularities caused by delayed adhesion or uneven matching of lamellar fibrils.

Intraoperative Optical Coherence Tomography for Enhanced Depth Visualization in Deep Anterior Lamellar Keratoplasty From the PIONEER Study.

Purpose: Deep anterior lamellar keratoplasty (DALK) is a challenging procedure that often results in conversion to penetrating keratoplasty. Preservation of Descemet membrane (DM) relies on indirect visualization of surgical planes. We describe a technique for enhanced visualization of key steps in DALK with intraoperative optical coherence tomography. Methods: Using a microscope-mounted spectral domain optical coherence tomography system, high-resolution images of various steps were obtained. Results: Specifically, images were obtained of the trephination depth and proximity of the cannula tract to DM. Other key steps such as air cannula placement, assessment of the DM position and integrity after attempted big-bubble delivery, and assessment of graft–host apposition were readily visualized. The presence of intrastromal emphysema after air injection decreased visualization of deeper structures. Conclusions: Intraoperative optical coherence tomography allows visualization of depth-dependent anatomy and changes from specific surgical interventions during DALK not appreciated with the en face operating microscope view and has the potential to facilitate big-bubble delivery. Clinical Trial Registration—URL: http://www.clinicaltrials.gov. Unique identifier: NCT02423161.

Successful Descemet's stripping automated endothelial keratoplasty for congenital hereditary endothelial dystrophy in a pediatric patient.

Endothelial keratoplasty, particularly Descemet’s stripping automated endothelial keratoplasty (DSAEK), has quickly become the standard of care for adult endothelial dysfunction [1–4]. As long-term follow-up data becomes available and surgeon comfort with the procedure increases, DSAEK is continually being applied to new diseases. Pediatric cases of endothelial dysfunction treated by DSAEK have already been reported for the treatment of bullous keratopathy following cataract surgery and Descemet’s membrane damage due to traumatic birth injury [5, 6]. Pineda et al. [7] reported a single case of attempted DSAEK in a 7-year-old boy with congenital hereditary endothelial dystrophy (CHED) which was converted to penetrating keratoplasty due to poor visualization and difficulty stripping the host Descemet’s membrane. The authors questioned whether DSAEK could be successfully performed for CHED. Mittal et al. [8] recently reported the first successful case of DSAEK in a 19-year-old male with CHED. To date, no successful reports of DSAEK as treatment for CHED in the pediatric age group have been published. In this paper, we report our successful technique and results in performing DSAEK for each eye of an eight-yearold child with CHED.

Prednisolone versus dexamethasone for prevention of pseudophakic cystoid macular edema

OBJECTIVE Prevention of cystoid macular edema (CME) is important to achieve good surgical outcomes after cataract surgery. Although many options for management exist, control of postoperative inflammation with topical steroids is one of the most commonly employed. We evaluated the difference in incidence of pseudophakic CME in patients treated with prednisolone or dexamethasone topical steroids. METHODS The study was a retrospective chart review of patients who had undergone phacoemulsification at the Cole Eye Institute of the Cleveland Clinic. Reviewable patient charts had to indicate the topical steroid used and whether or not an additional medication (e.g., nonsteroidal anti-inflammatory drugs [NSAIDs]) was used after surgery. Excluded were patients who underwent combination procedures (e.g., trabeculectomy), perioperative anti-vascular endothelial growth factor or intraocular steroid, eyes with epiretinal membrane or prior retinal vein occlusion, those who developed postoperative endophthalmitis, patients with less than 3 months of follow-up, and patients who received topical NSAIDs. Pseudophakic CME was defined as new or worsening macular edema on optical coherence tomography within the first 3 months after cataract extraction. RESULTS In total, 1135 patient charts were included in the analysis; 721 patients were treated with prednisolone acetate, and 414 were treated with dexamethasone. Patient characteristics were similar between the 2 treatment groups. No significant difference was found in the rate of postoperative CME for patients receiving prednisolone or dexamethasone (4.0% vs 4.1%, p = 0.94). CONCLUSIONS There was no significant difference in the rate of pseudophakic CME when either prednisolone acetate or dexamethasone sodium phosphate was used after cataract surgery.

Inadvertent placement of a glaucoma tube into the graft-host interface of an eye with previous Descemet stripping automated endothelial keratoplasty.

Purpose:The aim of this study was to report the inadvertent insertion of a glaucoma tube into the graft-host interface in a patient with previous Descemet stripping automated endothelial keratoplasty (DSAEK). Methods:This is a retrospective case report. Results:A 56-year-old aniridic woman with a history of multiple failed penetrating keratoplasties (PKPs) and glaucoma underwent DSAEK under failed PKP of her left eye at our institution. After undergoing a subsequent glaucoma tube placement by an outside glaucoma specialist, the tube was identified in the DSAEK-PKP interface. The tube was successfully repositioned at the time of repeat PKP with placement of a Boston type I keratoprosthesis. Conclusions:Inadvertent insertion of a glaucoma tube into the DSAEK interface may result in ocular morbidity in patients with previous DSAEK surgery.

Spontaneous regression of epithelial downgrowth from clear corneal phacoemulsification wound

Purpose To report a case of spontaneous regression of optical coherence tomography (OCT) and confocal microscopy-supported epithelial downgrowth associated with clear corneal phacoemulsification wound. Observations A 66-year-old Caucasian male presented two years after phacoemulsification in the left eye with an enlarging cornea endothelial lesion in that eye. His early post-operative course had been complicated by corneal edema and iris transillumination defects. The patient presented to our clinic with a large geographic sheet of epithelial downgrowth and iris synechiae to the temporal clear corneal wound. His vision was correctable to 20/25 in his left eye. Anterior segment OCT showed a hyperreflective layer on the posterior cornea with an abrupt transition that corresponded to the clinical transition zone of the epithelial downgrowth. Confocal microscopy showed polygonal cells with hyperreflective nuclei suggestive of epithelial cells in the area of the lesion with a transition to a normal endothelial cell mosaic. Given the lack of glaucoma or inflammation and the relatively good vision, the plan was made to closely monitor for progression with the anticipation that he may require aggressive surgery. Over course of subsequent follow-up visits at three, seven and ten months; the endothelial lesion receded significantly. Confocal imaging in the area of the previously affected cornea showed essentially normal morphology with anan endothelial cell count of 1664 cells/mm2. Conclusions and importance Epithelial downgrowth may spontaneously regress. Though the mechanism is yet understood, contact inhibition of movement may play a role. Despite this finding, epithelial downgrowth is typically a devastating process requiring aggressive treatment.

Surgical Drainage of Lymphangiectasia Haemorrhagica Conjunctivae.

Purpose: To report a case of nonresolving lymphangiectasia haemorrhagica conjunctivae (LHC) successfully treated with surgical drainage. Methods: Retrospective case report. Results: A 17-year-old white girl presented with a history of a large red lesion affecting her right eye. Approximately 1 year earlier, she had noticed a small painless “red spot” affecting the inferior aspect of the conjunctiva of her right eye. Three months before presentation, she noticed a sudden increase in the size of the lesion. There was no history of trauma, and she was not a contact lens wearer. Her medical history was remarkable for a remote seizure disorder which had been stable on levetiracetam. Magnetic resonance imaging/magnetic resonance angiography of the brain and orbits was unremarkable. Anterior segment fluorescein angiography did not show any flow in the lesion, indicating a lymphatic origin of channels. Surgical drainage of the lesion was performed while sparing the affected conjunctiva resulting in an excellent cosmetic outcome. Incisional biopsy confirmed the diagnosis of LHC. The patient remained free of recurrence 6 months after the procedure. Conclusions: Nonresolving LHC can be managed successfully with conjunctival sparing surgical drainage with an excellent cosmetic outcome.

Rates of Intraocular Pressure Elevation and Use of Topical Antihypertensive Medication After Descemet Stripping Automated Endothelial Keratoplasty

Purpose: To investigate intraocular pressure (IOP) elevation and medication augmentation after Descemet stripping automated endothelial keratoplasty (DSAEK) in those with and without glaucoma. Methods: The records of 379 patients who underwent DSAEK at the Cleveland Clinic Foundation between January 2009 and 2014 were retrospectively reviewed. Postoperative IOP elevations were considered significant if IOP was ≥22 mm Hg on at least 1 follow-up visit or if it increased by ≥10 mm Hg from baseline. Results: The incidence rate of IOP elevation was 4% per person-month (confidence interval [CI], 3%–6%) in patients with preexisting glaucoma and 3% (CI, 2%–4%) in those without. Rates of medication augmentation were 4% per person-month (CI, 3%–5%) in patients with glaucoma and 1.8% (CI, 1.4%–2.4%) in those without. Incidence rates for both outcomes peaked at 1 month. Whites had nearly a 47% lower incidence of IOP elevation compared with nonwhites (P = 0.004); patients with pseudophakic bullous keratopathy had a 54% higher incidence of IOP elevation (P = 0.024); and those with Fuchs endothelial corneal dystrophy had a 36% lower incidence (P = 0.024). Patients with glaucoma had over a 2-fold higher incidence of medication augmentation compared with those without (hazard rate ratio = 2.08, P < 0.001). Conclusions: The incidence of post-DSAEK IOP elevation did not significantly differ by glaucoma status, although patients with glaucoma were more likely to have escalation of topical antihypertensive therapy. The incidence of IOP elevation was significantly associated with pseudophakic bullous keratopathy and nonwhite race. These patients should be followed closely in the early postoperative period, as elevated IOP can be a serious consequence of DSAEK.

Ophthalmic viscosurgical device–assisted incision modification for the big-bubble technique in deep anterior lamellar keratoplasty

&NA; We describe several simple modifications of the big‐bubble technique to improve surgeon comfort and reduce the risk for complications, with emphasis on our ophthalmic viscosurgical device (OVD)‐assisted incision technique. By coating the overlying stroma with OVD prior to entering the big bubble, space is maintained in the pre‐Descemet plane. This prevents collapse of the big bubble and allows an air–OVD exchange. We have successfully used this technique in 72 consecutive cases without a perforation during the entry incision to the bubble space of the DALK procedure. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned. Additional disclosures are found in the footnotes.