Matthew T. Feng

Air reinjection and endothelial cell density in Descemet membrane endothelial keratoplasty: Five-year follow-up

Purpose To evaluate 5‐year endothelial cell loss after Descemet membrane endothelial keratoplasty (DMEK), compare it with reported rates for Descemet‐stripping endothelial keratoplasty (DSEK) and penetrating keratoplasty (PKP), and investigate potential association between cell loss and air reinjection. Setting Price Vision Group, Indianapolis, Indiana, USA. Design Retrospective comparative case series. Methods Consecutive DMEK procedures performed between March 2008 and April 2013 were reviewed. The inclusion criterion was at least 6 months of follow‐up. Endothelial cell density was recorded preoperatively and 1, 3, and 6 months and annually through 5 years postoperatively. Potential association between air reinjection and endothelial cell loss was evaluated by repeated measures analysis of variance. Results Of the 926 procedures performed, 673 eyes met the inclusion criterion. Indications for DMEK included Fuchs dystrophy (n = 595), pseudophakic corneal edema (n = 30), failed endothelial keratoplasty (n = 39), and failed PKP (n = 9). The median endothelial cell loss was 26% at 1 month, increasing to 39% at 5 years in cross‐sectional and longitudinal analyses. Cell loss was similar in eyes with no (n = 471) or 1 (n = 155) air reinjection and significantly higher in eyes with 2 or more air reinjections (n = 47, P=.017). Conclusions The median 5‐year cell loss of 39% with DMEK compared favorably with prior reports of DSEK (53%) and PKP (70%) performed for similar indications. Similar to DSEK, most DMEK cell loss was associated with the surgical procedure itself; subsequent cell loss occurred at a slower rate than after PKP. Cell loss was not significantly increased in eyes with a single air reinjection. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

Pain perception in sequential cataract surgery: Comparison of first and second procedures

PURPOSE: To compare pain and anxiety between first and second cataract extractions under topical anesthesia with monitored anesthesia care. SETTING: University ophthalmology clinic. DESIGN: Cohort study. METHODS: Consecutive adults having bilateral sequential clear corneal cataract extraction using phacoemulsification under topical anesthesia with monitored anesthesia care were recruited. Exclusion criteria included baseline eye pain, poor comprehension, and complicated cataract extraction. Patients completed 4 short perioperative surveys with each cataract extraction as follows: the Amsterdam Preoperative Anxiety and Information Scale (APAIS) and the State‐Trait Anxiety Scale (STAI) preoperatively and a 0‐to‐10 visual analog scale pain survey twice after surgery. Pain and difference in pain were the primary outcomes. RESULTS: Of the 65 patients who completed the study, 26 (40%) reported higher visual analog scale pain scores for the second cataract extraction. Overall, the median pain score was 0 (range 0 to 6) for the first cataract extraction and 1 (range 0 to 9) for the second (P=.004). By 1 day postoperatively, the pain scores were similar (median 0; range 0 to 9; P=.58). Both APAIS and STAI anxiety scores decreased between surgeries (P=.003 and P<.001, respectively). CONCLUSIONS: Although cataract extraction remained relatively painless under topical anesthesia with monitored anesthesia care, there was a subtle increase in pain in the second surgery relative to the first. This appears to be associated with decreased preoperative anxiety and may be related to the amnestic effects of intravenous sedation. These data may explain a common operative observation. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Loteprednol Etabonate 0.5% Gel Vs. Prednisolone Acetate 1% Solution After Descemet Membrane Endothelial Keratoplasty: Prospective Randomized Trial.

Purpose: To compare intraocular pressure (IOP) elevation and graft rejection with loteprednol etabonate 0.5% gel and prednisolone acetate 1% solution after Descemet membrane endothelial keratoplasty (DMEK). Methods: In this prospective, evaluator-masked trial, 167 patients were randomized to loteprednol or prednisolone in a 1:1 ratio 1 month after DMEK; 66 fellow eyes were enrolled and assigned to the opposite treatment. Dosing was 4 times daily for 2 months, thrice daily for 1 month, twice daily for 1 month, and once daily for 7 months. The main outcomes were IOP elevation (defined as IOP ≥ 24 mm Hg or an increase of ≥10 mm Hg over the baseline preoperative level) and immunologic rejection episodes, assessed by Kaplan–Meier survival analysis and proportional hazards modeling. Results: A total of 233 eyes were assigned to treatment. Loteprednol etabonate 0.5% gel and prednisolone acetate 1% solution were equally effective in preventing immunologic rejection episodes; none (0%) occurred with either treatment (P = 1). IOP elevation was twice as likely in the prednisolone-treated eyes (relative risk = 2.3, 95% confidence interval: 1.2–4.5, P = 0.016). The proportion with IOP elevation was 25% in prednisolone-treated eyes versus 11% in loteprednol-treated eyes (P = 0.013). In 66 subjects with fellow eyes assigned to opposite treatments, an IOP increase of ≥10 mm Hg was significantly more likely in the prednisolone-treated eye (P = 0.031). Conclusions: Loteprednol etabonate 0.5% gel was as effective as prednisolone acetate 1% solution in preventing immunologic graft rejection episodes after DMEK and was significantly less likely to cause IOP elevation. Clinical Trial Registration—URL: http://www.clinicaltrials.gov. Unique identifier: NCT01853696.

Evolution of Endothelial Keratoplasty: Where Are We Headed?

In less than 10 years, the proportion of endothelial keratoplasty (EK) procedures has increased from less than 5% of the corneal grafts in the United States to over half. EK has made corneal grafts safer and provides better and more predictable visual results than standard full-thickness penetrating keratoplasty. Descemet membrane endothelial keratoplasty in particular has dramatically reduced the risk of rejection, allowing reduction in topical corticosteroid use, resulting in a lower incidence of steroid-induced intraocular pressure elevation. By removing the confounding effects of ocular surface disease, which is exacerbated by the sutures and anesthetic corneas associated with full-thickness grafts, EK has revealed that the greatest risk factor for graft failure is filtration surgery, particularly aqueous shunts. As the use of glaucoma filtering tubes continues to increase, they may become a leading cause of corneal decompensation.

International values of corneal elevation in normal subjects by rotating Scheimpflug camera.

PURPOSE: To examine whether clinically significant differences exist in corneal elevation data from a sampling of countries worldwide. SETTING: International multicenter. DESIGN: Evaluation of diagnostic test or technology. METHODS: One randomly selected eye of normal adults from 8 countries spanning 6 continents was examined using the Pentacam Eye Scanner. Anterior and posterior elevations were measured at the apex and thinnest point. Differences between countries were assessed by Kruskal‐Wallis. Normative thresholds were defined according to the Tukey method. RESULTS: The study examined 1 eye of 555 patients. Median elevations were similar across countries. Upper limits of normal for collective international data were 3.5 μm, 6.0 μm, 7.5 μm, and 13.5 μm at the anterior apex, anterior thinnest point, posterior apex, and posterior thinnest point, respectively. These and country‐specific thresholds were similar to normal values from previous data; however, country‐specific thresholds flagged additional eyes in China, Egypt, and India. Those thresholds were 4.5 μm at the anterior thinnest point (China and Egypt), 7.4 μm at the posterior apex (India), and 11.0 μm and 12.0 μm at the posterior thinnest point (China and Egypt, respectively). CONCLUSIONS: In general, international variations were clinically insignificant; thus, current screening guidelines maintained their applicability. Notable exceptions were China, Egypt, and India, where country‐specific thresholds may better reflect the test populations and minimize potential false negative results from screening. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned. Additional disclosures are found in the footnotes.

One-year outcomes in eyes remaining phakic after Descemet membrane endothelial keratoplasty.

Purpose To assess 1‐year outcomes in patients remaining phakic after Descemet membrane endothelial keratoplasty (DMEK). Setting Private clinic, Indianapolis, Indiana, USA. Design Interventional case series. Methods Data on consecutive DMEK cases with retention of the crystalline lens were reviewed. The outcome measures were development or progression of postoperative lens opacity, performance of cataract extraction, endothelial cell loss, and corrected distance visual acuity (CDVA) at 1 year. The rate of and risk factors for cataract formation and extraction were analyzed using multivariate proportional hazards modeling and Kaplan‐Meier survival analysis. Results Of the 49 eyes, 15 (31%) had trace nuclear sclerosis and 34 (69%) had clear lenses preoperatively. The median patient age was 50 years. Forty‐eight eyes (98%) were treated for Fuchs dystrophy. The median follow‐up after DMEK was 12 months. All grafts cleared and remained clear. Cataract progression occurred postoperatively in 37 eyes (76%); cataract surgery was performed in 16 eyes (33%). Patients older than 50 years had a higher risk for cataract progression after DMEK (P=.0094). The median endothelial cell loss was 25% within the first year. The median CDVA was 20/20 at 1 year. Conclusions Descemet membrane endothelial keratoplasty accelerated the natural rate of cataract formation, consistent with data on other types of corneal transplantation including penetrating keratoplasty and Descemet‐stripping automated endothelial keratoplasty. Patients older than 50 years had higher risk for cataract progression than younger patients. The majority of patients achieved 20/20 CDVA. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

Repeat Descemet Membrane Endothelial Keratoplasty: Secondary Grafts with Early Intervention Are Comparable with Fellow-Eye Primary Grafts

PURPOSE To evaluate the outcomes of secondary Descemet membrane endothelial keratoplasty (DMEK) after failed primary DMEK. DESIGN Retrospective, interventional case series. PARTICIPANTS Fifty-five DMEK recipients 42 to 89 years of age. METHODS An initial consecutive series of 1655 DMEK surgeries was reviewed to identify cases of secondary DMEK after failed primary DMEK (n = 55). A paired fellow-eye analysis was performed with a subgroup of 29 patients who underwent secondary DMEK in 1 eye and successful primary DMEK in the fellow eye. MAIN OUTCOME MEASURES Corrected distance visual acuity (CDVA), central corneal thickness, and 1-year endothelial cell loss. RESULTS The median follow-up after DMEK regraft was 18 months (range, 3-61 months). All 55 regrafts cleared, 8 (15%) had air reinjected to promote attachment, 1 eye (2%) with trabeculectomy and progressive synechiae demonstrated late endothelial failure, and no rejection episodes occurred (0%). In the paired analysis, the median duration of endothelial decompensation before the regraft was 21 days (range, 2-133 days). At 1, 3, 6, or 12 months, CDVA did not differ between the primary and secondary grafts in fellow eyes (mean difference, ≤2 Snellen letters; P > 0.05 at all examinations). At 1 year, the visual acuity was ≥20/20 in 61%, ≥20/25 in 81%, and ≥20/40 in 100% of the secondary grafts in the paired analysis, excluding 1 eye with retinal problems. Vision differed by ≤1 line between fellow eyes in all but the 1 patient with the longest time to regraft (133 days), who demonstrated central haze and irregular astigmatism from anterior stromal scarring during that period. At 1 year, CDVA associated with the scarring was 20/40 versus 20/20 for the fellow-eye primary graft. The central corneal thickness was comparable between fellow-eye primary and secondary grafts at 3, 6, and 12 months (mean difference at 1 year, 2 μm; P = 0.57). The 1-year endothelial cell loss was comparable in primary and secondary grafts (27% vs. 31%, respectively; P = 0.58). CONCLUSIONS In patients who received prompt intervention to minimize the duration of central corneal decompensation, the visual outcomes with secondary DMEK matched the fellow-eye visual outcomes with primary DMEK.

Implementation of the posterior chamber intraocular lens intrascleral haptic fixation technique (glued intraocular lens) in a United States practice: Outcomes and insights.

Purpose To evaluate intrascleral haptic posterior chamber intraocular lens (PC IOL) fixation (glued IOL). Setting North American tertiary referral center, private practice. Design Noncomparative interventional case series. Methods A retrospective review of early cases of the technique performed at the same center evaluated outcomes and complications. Based on early experience, 2 modifications were made to the standard technique. The first was to transition to IOLs with more flexible and resilient haptic materials than poly(methyl methacrylate) or polypropylene. Second, the scleral flap was created with a diamond knife and only 2 edges were lifted, leaving the side adjacent to the tunnel uncut. This allowed reliable creation of a scleral tunnel at equal depth to the flap bed and improved ease of subsequent haptic enclavation; it also strengthened the anterior aspect of the tunnel entrance. Results Fifty PC IOLs were successfully placed with intrascleral haptic fixation by 1 of 3 experienced surgeons to treat a variety of IOL complications or aphakia. Two cases involved the successful placement of iris prostheses. Staged endothelial keratoplasty was performed in 11 cases without complication. No IOL dislocated, decentered, or was unstable. Self‐resolving hypotony occurred in 11 eyes (22%). The median visual acuity improved from 20/200 to 20/50. Conclusions The glued IOL technique reliably provided secure IOL fixation in the absence of capsule support and successfully treated a variety of IOL complications, aphakia, and aniridia. Minor technique modifications minimized some difficulties associated with this surgery. Financial Disclosures Drs. McKee and Feng are consultants to Mastel Precision Surgical Instruments, Inc. Dr. F. Price is a consultant to Ophtec USA, Inc. Drs. F. Price and M. Price are consultants to Staar Surgical Co.

Non-traumatic Alternaria keratomycosis in a rigid gas-permeable contact lens patient

Alternaria encompasses nearly 50 species of ubiquitous, saprophytic, dematiaceous ascomycetes that are normal conjuctival flora in some individuals but can also cause opportunistic corneal infections, especially in the settings of agricultural trauma, surgery and topical steroid and antibiotic use. Soft contact lens wear may confer an additional risk of fungal keratitis but is rarely implicated with Alternaria .1 2 Here, we report the first case, to our knowledge, of non-traumatic, RGP-related Alternaria keratomycosis. Of 62 published cases of Alternaria keratomycoses (table 1), none involved rigid gas-permeable contact lens (RGP) wear. View this table: Table 1 Alternaria keratomycosis reported in the literature A 72-year-old Caucasian female RGP wearer of 12 years complained of gradual left eye burning and redness for 1 week. History was remarkable only for remote, uncomplicated penetrating keratoplasty (PKP) for keratoconus. At presentation, uncorrected visual acuity was 20/200 in …

Prevention and Management of Pupil Block After Descemet Membrane Endothelial Keratoplasty.

Purpose: To assess frequency, associations, and outcomes of full air fill after Descemet membrane endothelial keratoplasty (DMEK). Methods: This retrospective study reviewed 368 consecutive DMEK cases performed to treat Fuchs dystrophy, bullous keratopathy, or failed keratoplasty. Primary outcomes were air bubble status, intraocular pressure, and incidence of pupil block and air reinjection. Results: Using an air management algorithm, slit-lamp assessment 1 hour after DMEK identified complete air fill in 80/368 eyes (22%). This spontaneously resolved in 45 eyes. Air was removed from 35 eyes (9%). Eyes that required air removal were more likely to have occluded iridotomy than did eyes in which the full air fill spontaneously resolved (23% vs. 6.6%, respectively), P = 0.05. Although full air fill was more likely after DMEK combined with cataract surgery (P = 0.001), air removal was more likely after DMEK-only procedures (P = 0.01). Eyes that underwent air removal tended to have lower rebubble rates, although this did not reach statistical significance (P = 0.06). No cases of pupillary block glaucoma occurred, and full air fill did not significantly affect 6-month postoperative vision or endothelial cell density. Conclusions: A careful air management strategy successfully prevented pupil block in eyes that developed full air fill. DMEK-only procedures were more likely to require air removal than those combined with cataract surgery, which suggests that decreased zonular flexibility may prevent the air bubble from taking a more spherical shape and more easily allow occlusion of iridotomy.