Kenneth M. Goins

Eye bank survey of surgeons using precut donor tissue for descemet stripping automated endothelial keratoplasty.

PURPOSE To assess surgeon satisfaction with precut corneal tissue from 1 eye bank for Descemet stripping automated endothelial keratoplasty (DSAEK). Surgical techniques and predictors of procedural success were also examined. METHODS A 19-question survey was completed by 53 surgeons around the United States for 197 DSAEK cases using prepared corneal allograft tissue from the Iowa Lions Eye Bank. Surgeries were performed between April 1 and December 31, 2006; surveys were completed retrospectively within a few weeks of surgery. RESULTS Tissue was found to be acceptable in 98% of DSAEK cases reported. Difficulties with precut tissue (eg, lack of anterior cap adherence to the posterior lamella, not visible or decentered central dot, anterior edge undermining) were reported in approximately 10% of cases. A rebubbling procedure was performed in 23% of cases for donor dislocations. The donor lenticule adhered, with resulting corneal deturgescence, in 86% of cases. Surgeons declared a successful procedure in 92% of cases. Of the 14 unsuccessful cases, donor tissue quality was the underlying etiology in only 1 case. Procedural success rates were related to surgeon experience (P = 0.002), lenticule adherence after only 1 anterior chamber air bubble (P = 0.005), no small perforations to release fluid (P = 0.005), and the presence of corneal deturgescence (P = 0.002). CONCLUSIONS The use of precut tissue for DSAEK is not associated with increased risk of complications related to tissue preparation. With standardization of precutting donor tissue, safety of DSAEK surgery may be improved while increasing surgeon efficiency.Background:Syphilis outbreaks among men who have sex with men (MSM) in the United States have raised concerns about increased HIV transmission in this population. We sought to estimate HIV incidence among men diagnosed with primary or secondary (P&S) syphilis in sexually transmitted disease (STD) clinics in Atlanta, San Francisco, and Los Angeles. Methods:We analyzed deidentified sociodemographic information from routine syphilis surveillance databases and matching remnant sera from consecutive male patients with P&S syphilis who were tested for syphilis at 3 public health laboratories during January 2004 through January 2006. Deidentified sera positive for Treponema pallidum by particle agglutination were screened for HIV-1 antibodies by enzyme immunoassay (EIA). Specimens that were confirmed HIV-positive by Western blot analysis were then tested for recent HIV infection using the less sensitive (LS) HIV-1 Vironostika EIA and BED HIV-specific IgG/total IgG assay. Results:Of 357 men with P&S syphilis (98 in Atlanta, 151 in San Francisco, and 108 in Los Angeles), 32% had primary syphilis and 85% were MSM (12% no MSM risk and 3% no information). The median age was 36 years; 40% were white, 31% black, 20% Hispanic, and 8% other. Among men with P&S syphilis, 160 (45%) were HIV-positive, of whom 8 were classified as having acquired recent HIV infection by the LS-Vironostika EIA (all confirmed by BED) and had no history of antiretroviral use or HIV-positive results >6 months earlier. Seven of the 8 men with recent HIV infection were MSM. The estimated HIV incidence was 9.5% per year (95% confidence interval [CI]: 2.9 to 16.0) among all men and 10.5% per year (95% CI: 2.7 to 18.3) among MSM. Conclusions:We found high HIV incidence among a high-risk population of US men diagnosed with P&S syphilis in STD clinics in Atlanta, San Francisco, and Los Angeles. Intensive integrated HIV/STD prevention programs are needed for this population.

Comparison of the femtosecond laser (IntraLase) versus manual microkeratome (Moria ALTK) in dissection of the donor in endothelial keratoplasty: initial study in eye bank eyes.

Purpose: To determine the safety and efficacy of a femtosecond laser (IntraLase) and manual microkeratome (Moria ALTK) in creating precut endothelial keratoplasty donor tissue. Methods: Sixteen corneoscleral buttons from 8 donors were evaluated within 2 days of the death of the donor. The mean donor age was 72 years, and mean death-to-preservation time was 11 hours. Eight eyes underwent deep lamellar keratectomy by using the femtosecond laser (IntraLase: firing rate, 30 kHz; lamellar cut energy, 7.4 μJ; side cut energy, 5.5 μJ; spot size, 10 μm; diameter, 9.0 mm; depth, 400 μm; spiral pattern), whereas the other 8 eyes were cut by using the Moria ALTK microkeratome (350-μm head). Ultrasonic pachymetry and endothelial cell density (ECD) were performed before and after keratectomy. The residual stromal bed was examined with electron microscopy to determine the smoothness of the surface. Cell viability was assessed by using a transferase dUTP nick end labeling (TUNEL) assay. Results: The mean preoperative pachymetry was similar in the microkeratome group and femtosecond laser group (P = 0.239). The microkeratome group obtained a consistently deeper keratectomy of 446 ± 25 versus 400 ± 41 μm in the laser group (P = 0.023). Similarly, the residual stromal bed was thinner in the microkeratome group (115 ± 28.5 vs. 177 ± 42 μm; P = 0.005). There was no statistically significant difference in the ECD between the 2 groups preoperatively or at 48 hours after keratectomy. Compared with the preoperative state, there was a 1% and 4% reduction of ECD in the microkeratome and femtosecond laser groups, respectively. Scanning electron microscopy of the stromal surface consistently showed a smoother contour in the manual microkeratome group. TUNEL assays indicate no significant endothelial cell loss in either the microkeratome group or the femtosecond laser group. Conclusions: The femtosecond laser (30 kHz) and the manual microkeratome are equally effective in creating precut endothelial keratoplasty donor tissue, with no detrimental effect on endothelial cell density. The microkeratome creates a smoother stromal surface and thinner endothelial discs. The femtosecond laser lamellar dissection depth is less deep, and the stromal surface is less smooth. This particular feature of femtosecond laser keratectomy may improve disc adherence, which continues to be a problem in endothelial keratoplasty. A prospective, randomized study is needed to evaluate postoperative vision and disc adherence by using both technologies in endothelial keratoplasty.

Diabetes mellitus increases risk of unsuccessful graft preparation in Descemet membrane endothelial keratoplasty: a multicenter study.

Purpose: The aim of this study was to evaluate preparation outcomes of tissue prepared for Descemet membrane endothelial keratoplasty (DMEK) from diabetic and nondiabetic donors. Methods: In this nonrandomized, consecutive case series, DMEK grafts were prepared from diabetic and nondiabetic donors by experienced technicians in 2 eye banks using slightly different, modified submerged manual preparation techniques to achieve “prestripped” graft tissue. Graft preparation results were analyzed retrospectively. The main outcome measure was the rate of unsuccessful (failed) DMEK graft preparations, defined as tears through the graft area that prevent tissue use. Results: A total of 359 corneas prepared from 290 donors (114 diabetic and 245 nondiabetic) were included in the statistical analysis of graft preparation failure. There were no significant differences between diabetic and nondiabetic donor tissue characteristics with respect to donor age, death to preservation time, death to preparation time, endothelial cell density, percent hexagonality, or coefficient of variation. DMEK tissue preparation was unsuccessful in 19 (5.3%) cases. There was a significant difference in the site-adjusted rate of DMEK preparation failure between diabetic [15.3%; 95% confidence interval (CI), 9.0–25.0] and nondiabetic donors (1.9%; 95% CI, 0.8–4.8), and the corresponding site-adjusted odds ratio of DMEK graft preparation failure in diabetic donor tissue versus nondiabetic donor tissue was 9.20 (95% CI, 2.89–29.32; P = 0.001). Conclusions: Diabetes may be a risk factor for unsuccessful preparation of donor tissue for DMEK. We recommend caution in the use of diabetic tissue for DMEK graft preparation. Further study is needed to identify what subset of diabetic donors is at risk for unsuccessful DMEK graft preparation.

Treatment of Contact Lens-related Ocular Surface Disorders with Autologous Conjunctival Transplantation

The authors describe two cases of chronic ocular surface disorder caused by the use of soft contact lenses. These cases demonstrated persistent corneal epithelial abnormalities, indolent ulceration, superficial stromal scarring, peripheral vascularization, and decreased visual acuity (worse than 20/400). Both cases were refractory to medical management, including discontinuation of contact lenses and topical medications. Autologous conjunctival transplantation restored the ocular surface with the return of good visual acuity (better than 20/40). Tissue culture demonstrated a decreased replication rate in the limbal epithelial cells, which suggests that epithelial stem cell dysfunction may be responsible for this ocular surface disease.

Donor-related Candida keratitis after Descemet stripping automated endothelial keratoplasty.

Purpose: To report 2 cases of donor-to-host transmission of Candida albicans interface keratitis after Descemet stripping automated endothelial keratoplasty (DSAEK). Methods: We performed clinical and microbiologic examinations on 2 patients who underwent DSAEK for pseudophakic corneal edema. Results: Two patients underwent uneventful DSAEK surgery using corneal tissue from the same donor. The donor corneoscleral rims were cultured at the time of surgery and both rims subsequently grew C. albicans and Candida glabrata. Approximately 5 weeks after surgery, infiltrates were noted in the DSAEK interface in both of these patients. Despite treatment with antifungal therapy, the Candida keratitis was unable to be controlled medically and required surgical intervention in each case, after which there was no recurrence of infection. Conclusions: Candida interface keratitis can occur after DSAEK. These 2 cases emphasize the importance of donor corneoscleral rim cultures, especially with the increase in lamellar and endothelial keratoplasty, which can make such interface infections more difficult to diagnose and treat. Patients with fungal positive donor corneal rim cultures should be prophylactically treated with antifungal therapy.

Retrospective review of graft dislocation rate associated with descemet stripping automated endothelial keratoplasty after primary failed penetrating keratoplasty

Purpose: To report the rate of graft dislocation in patients who underwent Descemet stripping automated endothelial keratoplasty (DSAEK) after a previous penetrating keratoplasty (PKP). Methods: Institutional review board-approved, multicenter, retrospective chart review. Inclusion criteria included: prior failed PKP and subsequent DSAEK. The primary outcomes measured in this study were the presence of a graft dislocation, rate of rebubble, and graft attachment. Additional variables included: presence of a prior glaucoma drainage device, graft-to-host size disparity, number of sutures remaining in PKP, and stripping of the Descemet membrane at the time of DSAEK surgery. Results: Ninety patients (97 eyes) were included in the study. In 31% (30 of 97), the endothelial graft dislocated after surgery. All 30 cases required a rebubble except 1, which reattached spontaneously. Ninety-eight percent (95 of 97) of all grafts remained attached for the duration of the follow-up period. Only 2 eyes (2.2%) required repeat graft. Endothelial grafts dislocated in 67% of patients with glaucoma draining devices. The dislocation rate for grafts larger than the host was 12 of 49 (24%), equal to the host was 3 of 17 (18%), and smaller than the host was 8 of 19 (42%). Dislocations occurred in 5 of 21 (24%) of grafts with sutures remaining and 22 of 76 (29%) of those with all sutures out. Five of 12 (42%) cases of grafts performed without stripping the Descemet had dislocations. Conclusions: The graft dislocation rate in DSAEK procedures after PKP is comparable to that after primary DSAEK cases. Donor grafts that are smaller than the host PKP and the presence of prior glaucoma drainage devices are risk factors for higher rates of graft dislocation.

Keratoplasty for Treatment of Acanthamoeba Keratitis

PURPOSE To evaluate and compare the outcomes of therapeutic keratoplasty (TKP) and optical keratoplasty (OKP) in the management of medically unresponsive Acanthamoeba keratitis and post-keratitis scarring, respectively. DESIGN Retrospective, nonrandomized, comparative, interventional case series. PARTICIPANTS Thirty patients with Acanthamoeba keratitis treated at a single center. METHODS Retrospective review of all cases of penetrating keratoplasty (PKP) or lamellar keratoplasty (LKP) performed for Acanthamoeba keratitis at a single center between January 1, 1980, and December 31, 2007. Inclusion criteria included histopathologic confirmation of Acanthamoeba organisms in the surgical specimen and at least 6 months of postoperative follow-up. MAIN OUTCOME MEASURES Postoperative complications, microbiological cure, graft survival, and visual acuity. RESULTS Thirty-one eyes of 30 patients met the inclusion criteria. This included 22 eyes (22 patients) that were initially treated with TKP (20 PKP/2 LKP) and 9 eyes (8 patients) treated with OKP (8 OKP/1 LKP). Of the 22 eyes treated with TKP, multiple keratoplasties (range, 2-6) were performed in 12 eyes (55%), whereas repeat keratoplasty was performed in only 1 eye (11%) treated with OKP (P = 0.004). Recurrent Acanthamoeba keratitis, glaucoma, early and late persistent epithelial defects, and endophthalmitis were more likely to occur after TKP than after OKP. A microbiological cure was achieved in all surgical cases. Among eyes treated with TKP, this required 1 keratoplasty in 14 eyes, 2 keratoplasties in 6 eyes, and 3 keratoplasties in 2 eyes. After the initial keratoplasty, Kaplan-Meier survivals after TKP were 45.5%, 45.5%, and 37.5% at 1 year, 5 years, and 10 years, respectively, compared with 100%, 100%, and 66.7%, respectively, after OKP (P = 0.004). The median visual acuity was 20/40 after TKP and 20/25 after OKP. Eyes treated with TKP were less likely to obtain visual acuity of 20/40 or better and more likely to have vision of 20/200 or worse. CONCLUSIONS Therapeutic keratoplasty can successfully treat medically unresponsive cases of Acanthamoeba keratitis, although multiple grafts may be required and the visual prognosis is guarded. Optical keratoplasty performed after resolution of active keratitis is associated with an excellent prognosis for both graft survival and visual outcome. FINANCIAL DISCLOSURE(S) The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Inhibition of proliferating lens epithelium with antitransferrin receptor immunotoxin

Abstract We investigated the effect of an antitransferrin receptor immunotoxin (454A12‐rRA) on proliferating human and baboon lens epithelium in vitro. Human and baboon lens epithelial cells grown in modified TC‐199 medium at 35 degrees Celsius in 7% C02 were seeded in 24 well plates at a density of 17,500 cells/ml to 40,000 cells/ml. The cells were exposed to various concentrations of 454A12‐rRA for seven days. The sensitivity of proliferating human lens epithelium to 454A12‐rRA was dependent on the dose, with a 60% to 70% reduction in cell counts at immunotoxin concentrations of 100 ng/ml and above. The immunotoxin had no significant effect on baboon lens epithelium in vitro, which suggests that it is specific for human tissue. By preventing the proliferation of human lens epithelial cells, immunotoxin 454A12‐rRA may be useful in the management of posterior capsule opacification after planned extracapsular cataract surgery.

New Insights into the Diagnosis and Treatment of Neurotrophic Keratopathy

Abnormalities of the ocular surface can be acquired or inherited disorders of the central nervous system. Loss of neural stimulation from the sensory division of the trigeminal nerve or from the autonomic nervous system can have devastating consequences on corneal epithelial wound healing and the precorneal tear film, leading to decreased vision. The pathogenesis of neurotrophic keratopathy is reviewed, and treatment modalities are recommended.

Relative strength of photodynamic biologic tissue glue in penetrating keratoplasty in cadaver eyes

Purpose: To compare the relative strength of photodynamic biologic tissue glue (PBTG) with that of 10‐0 nylon sutures in closing penetrating keratoplasty (PKP) wounds in cadaver eyes. Setting: Corneal Research Laboratory, University of Chicago, Chicago, Illinois, USA. Methods: A 7 mm central corneal trephination was performed on 8 recently enucleated human eyes. Each corneal button was removed and then resutured in its original position, using 4 interrupted 10‐0 nylon cardinal sutures and PBTG (n = 7) or 16 interrupted 10‐0 nylon sutures (n = 1). Wound leak and incisional bursting pressures were determined. Results: The average pressure at which wound leak and iris prolapse occurred was 124 mm Hg (range 70 to 180) and 185 mm Hg (range 90 to 300), respectively. The pressure required to create wound leak increased as the time between glue application and pressurization of the globe lengthened (mean 22 minutes, range 5 to 60 minutes), indicating that the bonding and stability of the adhesive increased with time. In contrast, the control eye developed wound leak at 70 mm Hg and iris prolapse at 300 mm Hg. Conclusions: Photodynamic biologic tissue glue was comparable to sutures in providing adequate corneal wound strength in PKP in a cadaver eye model. Wound closure with PBTG may reduce the number of sutures required in corneal transplantation and decrease the incidence of suture‐related complications and allograft rejection.