Kristiana D. Neff

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.

Factors Associated with Intraoperative Floppy Iris Syndrome

PURPOSE To identify factors associated with intraoperative floppy iris syndrome (IFIS) in patients undergoing routine phacoemulsification. DESIGN Comparative case series. PARTICIPANTS Analysis of 899 eyes of 660 patients undergoing routine cataract surgery. METHODS All routine cases of cataract extraction with posterior chamber intraocular lens implantation between September 1, 2005, and August 31, 2006, were documented. Pertinent patient information, including age, gender, race, medical history, and current medication use (including tamsulosin [Flomax, Boehringer-Ingelheim, Ingelheim, Germany], other alpha(1)-antagonists, angiotensin antagonists, anticholinergics, cholinergic agonists, muscle relaxants, nitric oxide donors, and saw palmetto), were collected at the time of surgery. A telephone survey was used to determine previous use of tamsulosin, other alpha(1)-antagonists, and saw palmetto. Cases were identified intraoperatively as IFIS or non-IFIS following the triad of criteria developed by Chang and Campbell. MAIN OUTCOME MEASURES Presence of IFIS associated with medication use and medical history. RESULTS Analysis showed IFIS in 27 patients (4.1%) representing 33 eyes (3.7%). Tamsulosin use (P<0.001) and history of alpha(1)-antagonist use other than tamsulosin (P = 0.01) were shown to strongly correlate with IFIS in our study. Hypertension was noted to be a significant variable via multivariable generalized estimating equations analysis (P = 0.04) with a prevalence of 75.8% in patients with IFIS versus 56.4% in patients without IFIS. Saw palmetto showed a slight, but statistically insignificant, trend that current use or history of use may be associated with IFIS. There were no cases of posterior capsular rupture or vitreous loss. CONCLUSIONS Exposure to tamsulosin highly correlates with IFIS. Use of other alpha(1)-antagonists is also associated with IFIS. Several patients in our series were identified to have IFIS with no history of alpha(1)-antagonist use, indicating that other etiologic factors, or a combination of factors, can also elicit this response. Multivariable regression analysis shows no proven relationship between IFIS and individual use of angiotensin antagonists, anticholinergics, cholinergic agonists, muscle relaxants, nitric oxide donors, or saw palmetto, and diabetes or congestive heart failure.

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.