Joseph M. Biber

Comparison of central corneal graft thickness to visual acuity outcomes in endothelial keratoplasty.

Purpose: To evaluate visual acuity outcomes after endothelial keratoplasty (EK) and describe the relationship to postoperative central corneal graft thickness as measured by anterior segment optical coherence tomography (AS-OCT). Methods: A retrospective case series of 33 eyes in 28 patients undergoing routine EK using precut eye bank tissue was designed. All patients underwent serial central graft thickness measurements with AS-OCT. Based on the median central graft thickness of all patients, the eyes were divided into 2 groups: thin EK and thick EK. Differences between the groups were compared. Results: The median postoperative graft thickness of all eyes was 131 μm. The eyes were divided into 2 groups based on this median: thin EK (graft thickness: ≤131 μm; range: 77-131 μm; average: 109 μm) and thick EK (graft thickness: >131 μm; range: 138-182 μm; average: 162 μm). There was no statistically significant difference in age, sex, or preoperative best spectacle-corrected visual acuity (BSCVA) between the 2 groups. Average postoperative follow-up was 12.8 months. The thin EK group showed better postoperative BSCVA compared with the thick EK group (P < 0.01). All thin EK eyes had BSCVA greater than or equal to 20/25 with 71% of eyes achieving BSCVA of 20/20. In contrast, only 50% of thick EK eyes reached BSCVA greater than or equal to 20/25 with 19% obtaining BSCVA of 20/20. Conclusions: Thin EK versus thick EK, as measured by AS-OCT in the postoperative period, showed a statistically significant improvement in BSCVA.

The cincinnati procedure: technique and outcomes of combined living-related conjunctival limbal allografts and keratolimbal allografts in severe ocular surface failure.

Purpose: To explain our preferred technique and evaluate the success of ocular surface transplantation using a combined living-related conjunctival limbal allograft (lr-CLAL) and keratolimbal allograft (KLAL) in patients with severe ocular surface failure and conjunctival deficiency. Methods: Retrospective study of all patients undergoing combined lr-CLAL/KLAL at the Cincinnati Eye Institute/University of Cincinnati. Patients were retrospectively analyzed for demographics, immunosuppression exposure, ocular surface stability, and need for keratoplasty. Snellen best-corrected visual acuity was evaluated preoperatively and at final visit. Results: Nineteen patients (24 eyes) underwent combined lr-CLAL/KLAL. Mean follow-up was 43.4 months (range: 12.2 to 125.5 months). At the last recorded visit, the ocular surface was stable in 54.2% (13 of 24), improved in 33.3% (8 of 24), and failed in 12.5% (3 of 24) of eyes. 79.2% (19 of 24) of patients underwent staged keratoplasty. For the primary keratoplasty, 73.7% (14 of 19) of patients underwent penetrating keratoplasty, 21.1% of patients underwent Boston type I keratoprosthesis, and 5.2% of patients underwent deep anterior lamellar keratoplasty; 57.9% of patients required repeat keratoplasty. Preoperative best-corrected visual acuity was 20/400 or worse in 87.5% (21 of 24); 75% (18 of 24) of eyes had improvement in visual acuity at the last follow-up with 70.8% of patients (17 of 24) achieving 20/125 vision or better. Of patients with a Boston keratoprosthesis, 90.0% (9 of 10) had an improvement in vision with 70.0% achieving 20/125 vision or better at the last follow-up. Conclusions: Ocular surface transplantation with a combined lr-CLAL/KLAL and staged keratoplasty is an effective procedure to improve visual acuity in patients with severe ocular surface disease and conjunctival deficiency. Keratoprosthesis after limbal stem cell transplantation is an alternative to penetrating or lamellar keratoplasty in this patient population.

Comparison of the incidence and visual significance of posterior capsule opacification between multifocal spherical, monofocal spherical, and monofocal aspheric intraocular lenses.

PURPOSE: To determine and compare the incidence of posterior capsule opacification (PCO) and neodymium:YAG (Nd:YAG) laser capsulotomy after implantation of 3 intraocular lens types (IOLs). SETTING: Storm Eye Institute, Medical University of South Carolina, Charleston, South Carolina, USA. METHODS: This retrospective chart review comprised eyes having uneventful phacoemulsification and implantation of 1 of 3 AcrySof IOLs: ReSTOR SN60D3 (multifocal spherical group), Natural SN60AT (monofocal spherical group), or IQ SN60WF (monofocal aspheric group). Eyes were matched by age, sex, and follow‐up. The PCO rate, Nd:YAG capsulotomy rate, time from surgery to PCO diagnosis, and time from surgery to Nd:YAG capsulotomy were assessed. RESULTS: Charts of 225 eyes (75 in each group) with a mean follow‐up of 15.9 months ± 6.5 (SD) were evaluated. The PCO rate was 42.7% in the multifocal spherical group, 28.0% in the monofocal spherical group, and 14.7% in the monofocal aspheric group. The Nd:YAG capsulotomy rate was 25.3%, 17.3%, and 4.0%, respectively. The difference in the Nd:YAG rate was statistically significantly higher in the multifocal and monofocal spherical groups than in the monofocal aspheric group (P<.001 and P<.008, respectively) but was not significantly different between the 2 spherical IOL groups (P = .232). The time from surgery to PCO documentation was not significantly different between the 3 groups. CONCLUSIONS: Intraocular lens configuration may have contributed to the difference in the PCO rate between the 2 spherical IOLs and the aspheric IOL. Based on the Nd:YAG rate as an indicator for visual significance, PCO may be less visually significant in eyes with the aspheric IOL than in eyes with 1 of the spherical IOLs.

The modified Cincinnati procedure: combined conjunctival limbal autografts and keratolimbal allografts for severe unilateral ocular surface failure.

Purpose: To describe the technique and present the outcomes of combined conjunctival limbal autografts (CLAU) and keratolimbal allografts (KLAL) for the treatment of unilateral severe ocular surface failure. Methods: Interventional case series. Eleven eyes of 11 patients who sustained chemical burns (4 alkali and 2 acid) and combined chemical/thermal burns (5 eyes) from firework explosions had combined CLAU/KLAL surgery. Keratoplasty was performed subsequently for residual corneal stromal scarring limiting visual acuity. Inclusion criteria included eyes with severe unilateral total ocular surface failure, controlled glaucoma, and reasonable eyelid apposition with no exposure. Exclusion criteria included patients with any ocular surface abnormality in the fellow eye and those with contraindications to systemic immunosuppression (SI). Outcome measures included Snellen best-corrected visual acuity (BCVA), ocular surface stability, SI exposure, and complications. Results: Preoperative BCVA was 20/400 or worse in all eyes. At the final follow-up (mean, 35.8 months; range, 12.1–105.9 months), 73% (8 of 11) eyes had BCVA of 20/80 or better (range, 20/25 to counting fingers), and ocular surface was stable in 82% (9 of 11). Ninety-one percent (10 of 11) had additional penetrating keratoplasty (PK) with a 60% (6 of 10 eyes) success rate. Three cases had subsequent Boston type 1 keratoprosthesis implantation after PK failure, and the fourth patient, at the time of his last follow-up visit, did not want further intervention for his edematous PK, which was a result of noncompliance-related corneal rejection. In eyes with more than 2 years of follow-up, SI was tapered at a mean of 16 months (range, 8–28 months). There were no intraoperative complications. No secondary tumors, cardiac events, or deaths occurred while patients were on SI. One patient developed secondary glaucoma refractory to medical management after subsequent PK, requiring cyclodiode laser. Conclusions: Combined CLAU/KLAL and staged keratoplasty is effective in improving vision and maintaining long-term ocular surface stability in patients with severe unilateral ocular surface disease and conjunctival deficiency.

Ocular surface stem cell transplantation rejection: incidence, characteristics, and outcomes.

Purpose: To describe the incidence, characteristics, risk factors, treatment, and outcomes of ocular surface stem cell transplantation (OSST) rejection. Methods: A chart review of patients who had OSST at a single institution between 1998 and 2010 was performed. Data were collected on patient demographics, type of OSST procedure, duration of immunosuppression, and rejection characteristics. Main outcome measures were ocular surface stability and improvement in best-corrected visual acuity. Results: Two hundred twenty-two eyes of 158 patients were included with mean follow-up of 62.7 months (range, 12.0–158.3 months). The most common indications for OSST were aniridia (46.4%), chemical/thermal injury (22.1%), and Stevens–Johnson syndrome (12.2%). The most common procedures performed were keratolimbal allograft (KLAL) alone (80.6%) and combined living-related conjunctival allograft (lr-CLAL)–KLAL (11.3%). Mean time on immunosuppression was 44.3 months (range, 7.6–138.2 months). Severe rejection occurred in 43 eyes (19.4%) with mean time to rejection being 15.2 months (range, 0.2–93.1 months). Low-grade rejection occurred in 26 eyes (11.7%) with mean time to rejection being 26.2 months (range, 1.3–64.9 months). At the final follow-up, 36.6% of eyes in the rejection group achieved a stable ocular surface compared with 71.9% of eyes in the nonrejection group (P < 0.0001). Risk factors associated with increased risk of rejection were younger age (P < 0.0001), KLAL alone (P = 0.049), and noncompliance with immunosuppression (P = 0.047). Conclusions: Ocular surface outcomes for patients with OSST rejection are poor, with the majority of patients having failed ocular surfaces despite treatment with increased immunosuppression and repeat OSST. It is critical for success that OSST patients are closely monitored for rejection and for compliance with immunosuppression.

Management of ocular stem cell disease.

Regeneration of the corneal epithelium occurs on average every 7 days. The source of renewal for these cells is a stem cell population located at the basal layer of the epithelium at the corneoscleral junction. This anatomic site is referred to as the limbus. Our understanding of the limbus and its collection of stem cells is continuing to evolve, as is our approach to ocular surface failure in patients with stem cell dysfunction. Limbal stem cell deficiency can be caused by multiple disease processes including aniridia, Stevens Johnson Syndrome (SJS), ocular cicatricial pemphigoid (OCP), and chemical/thermal/mechanical injuries. Clinically, it presents with loss of the palisades of Vogt, conjunctivalization of the corneal surface, and a persistent epithelial defect. Histologically, the hallmark of limbal stem cell deficiency is the presence of conjunctival goblet cells in the corneal epithelium. The purpose of this paper is to explain our approach to patients with ocular surface disease. Management decisions about these challenging patients are dependent on the severity and staging of the disease. There are multiple approaches to the surgical management of these patients and the postoperative course can often be filled with unique challenges as well. Often, the ultimate goal of ocular surface reconstruction is to provide an adequate environment for an optical keratoplasty to be successful and restore a patient’s vision in the long term.