Michael Tsatsos

Epidemiologic survey of pemphigus vulgaris with oral manifestations in northern Greece: Retrospective study of 129 patients

Objective  To evaluate the epidemiology of pemphigus vulgaris (PV) in a Greek population and to compare it with other countries.

Impact of graft thickness on visual acuity after Descemet's stripping endothelial keratoplasty

Objective To evaluate the relationship, over time, between central graft thickness and visual acuity following Descemets stripping endothelial keratoplasty (DSEK). Methods A retrospective analysis of 70 consecutive cases of DSEK. All donor lenticules were dissected manually. Serial postoperative measurements of central graft and total corneal thicknesses were made using anterior segment optical coherence tomography. Visual acuity, refraction and patient demographics were collected from case notes. The correlation between central graft thickness and visual acuity at serial time points was calculated. Results The median age at surgery was 75 years (lower quartile (LQ) 66, upper quartile (UQ) 83, range 36–90 years). Nineteen eyes were excluded from statistical analysis, leaving 51 eyes of 46 patients remaining. Last follow-up occurred a median of 12 months postoperatively (LQ 6, UQ 23, range 4–38 months). The median preoperative visual acuity was 0.71 logarithm of the minimum angle of resolution (logMAR), improving to 0.34 logMAR postoperatively (p<0.001, n=43). Median graft thickness decreased from 209 μm at day 1 to 142 μm at last follow-up (p<0.001). No statistically significant correlation was found between central total corneal thickness and visual acuity at any time point. Except for a single time point, no statistically significant correlation was found between central graft thickness and visual acuity. Conclusion There is no clear association between central graft, or total corneal, thickness and visual acuity following DSEK.

Herpes simplex virus keratitis: an update of the pathogenesis and current treatment with oral and topical antiviral agents.

Ophthalmic herpes simplex viral keratitis is responsible for a range of ocular manifestations from superficial epithelial disease to stromal keratitis and endotheliitis. The Herpetic Eye Disease Study has guided the management of herpetic eye disease for almost twenty years, but newer medications such as valacyclovir are now available and are considered to have better bioavailability than acyclovir. In this review, we examine the existing evidence on the pathogenesis of different ophthalmic herpes simplex viral keratitis disease modalities and the role of oral and topically administered antiviral drugs in the treatment of herpes simplex viral keratitis.

Determinants of visual quality after endothelial keratoplasty

Endothelial keratoplasty is now favored over full-thickness penetrating keratoplasty for corneal decompensation secondary to endothelial dysfunction. Although endothelial keratoplasty has evolved as surgeons strive to improve outcomes, fewer patients than expected achieve best corrected visual acuity of 20/20 despite healthy grafts and no ocular comorbidities. Reasons for this remain unclear, with theories including anterior stromal changes, differences in graft thickness and regularity, induced high-order aberrations, and the nature of the graft-host interface. Newer iterations of endothelial keratoplasty such as thin manual Descemet stripping endothelial keratoplasty, ultrathin automated Descemet stripping endothelial keratoplasty, and Descemet membrane endothelial keratoplasty have achieved rates of 20/20 acuity of approximately 50%, comparable to modern cataract surgery, and it may be that a ceiling exists, particularly in the older age group of patients. Establishing the relative contribution of the factors that determine visual quality following endothelial keratoplasty will help drive further innovation, optimizing visual and patient-reported outcomes while improving surgical efficacy and safety.

Subconjunctival triamcinolone acetonide in the management of ocular inflammatory disease.

PURPOSE To review the existing evidence that supports the subconjunctival use of triamcinolone acetonide (TA) in the treatment of various ophthalmic diseases. METHODS A literature search was performed for published articles about the pharmacokinetic (PK) and pharmacodynamic characteristics of triamcinolone, as well as its potential ophthalmic use, focused mainly in the subconjunctival mode of delivery. Search terms included corticosteroids, triamcinolone, ocular, subconjunctival, and ophthalmic. RESULTS Corticosteroids represent the mainstay of treatment of ocular inflammation, exerting their action by affecting multiple pathways of the inflammatory response, making them particularly effective in the majority of cases. However, due to the number and severity of the side effects associated with their use, they have to be given with caution. Corticosteroids can be given topically, subconjunctivally, intraocularly, and systemically to treat a variety of ocular diseases with specific pharmacological and PK characteristics. Triamcinolone is one of the most widely used corticosteroids in the treatment of ocular inflammation. This glucocorticoid used subconjunctivally was proven to be particularly safe and effective in some common and important inflammatory ophthalmic diseases such as anterior scleritis, uveitis, and corneal graft rejection. Further, there are other indications for its successful use where data exist, but somehow less abundant. CONCLUSIONS This article highlights the potential of TA to complement the treatment armamentarium of anterior segment inflammation.

Is accelerated corneal collagen cross-linking for keratoconus the way forward? No

Collagen cross-linking (CXL) was introduced in the late nineties and was later adopted as a treatment option for keratoconus, pellucid marginal degeneration, and post-LASIK ectasia in 2003.1, 2, 3 CXL is the only treatment modality for these conditions that addresses the underlying stromal weakening and thus halts disease progression. Recently, accelerated CXL was proposed as an alternative technique, whereby corneal stiffening can be achieved with higher fluence and reduced overall exposure time.

Presoaking with BSS used for thin manually dissected DSEK (TMDSEK): a viable option for thin DSEK

AimTo describe a novel technique for the safe manual dissection of thin donor lenticules in 10 consecutive patients undergoing DSEK surgery.MethodsA key element of our new technique was to presoak the donor cornea in balanced salt solution (BSS) for 30 min before manual dissection. The cornea was placed on an artificial anterior chamber and pressure in the chamber was maintained at 80 mm Hg. The limbus of the donor cornea was incised to the same depth as the central corneal thickness. Lamellar dissection was started with the short side of the Morlet dissector (Duckworth & Kent Ltd) and completed using the lamellar (less sharp) end of the Morlet dissector. Outcomes of 10 consecutive cases of thin manually dissected DSEK (TMDSEK) were prospectively analysed for thickness and visual outcome.ResultsMean graft thicknesses measured less than 100 μm at 1 month post surgery (mean thickness 90.7 μm, range 48–137 μm, SD 29.96 μm). Presoaked donor corneal pachymetry was strongly negatively correlated with graft thickness (correlation r=−0.75, P<0.05).DiscussionOur dissection technique achieves consistently thin endothelial donor corneal grafts that can be safely produced with minimal financial investment and no limitations on surgical time. This technique is likely to be of significant importance for a large proportion of the eye centres where microkeratomes may not be routinely available.

Neuropathic Pain in Multiple Sclerosis Improved With Oral Famciclovir: A Case Report.

Multiple sclerosis can be a debilitating disease that is often associated with neuropathic pain and discomfort in the trigeminal region. This can pose a therapeutic challenge as the benefits of the treatment options have to be outweighed against significant side effects. The authors present the case of a 67-year-old man, whose control of trigeminal neuralgia with botulinum toxin A injections was lost after an episode of herpes labialis and herpes zoster infection. The pain management of the patient during the episodes of herpes simplex and varicella zoster infections was greatly improved with famciclovir treatment, and subsequently control of trigeminal neuralgia was regained with botulinum toxin A injections. This case serves to highlight the potential association of multiple sclerosis with herpetic infections as well as the treatment challenges, especially management of pain, which they can possess.

Endothelial keratoplasty: is Descemet membrane endothelial keratoplasty the Holy Grail of lamellar surgery? No

Endothelial keratoplasty: is Descemet membrane endothelial keratoplasty the Holy Grail of lamellar surgery? No

Herpes simplex virus keratitis: an update of the pathogenesis and current treatment with oral and topical antiviral agents - response: Herpes simplex virus keratitis

1. Tsatsos M, MacGregor C, Athanasiadis I, Moschos MM, Hossain P, Anderson D. Herpes simplex virus keratitis: an update of the pathogenesis and current treatment with oral and topical antiviral agents. Clin Exp Ophthalmol 2016; 44: 824–37. 2. Serna-Ojeda JC, Ramirez-Miranda A, Navas A, Jimenez-Corona A, Graue-Hernandez EO. Herpes simplex virus disease of the anterior segment in children. Cornea 2015; 34: S68–71. 3. Liu S, Pavan-Langston D, Colby KA. Pediatric herpes simplex of the anterior segment: characteristics, treatment, and outcomes. Ophthalmology 2012; 119: 2003–8. 4. Schwartz GS, Holland EJ. Oral acyclovir for the management of herpes simplex virus keratitis in children. Ophthalmology 2000; 107: 278–82. 5. Hsiao CH, Yeung L, Yeh LK, et al. Pediatric herpes simplex virus keratitis. Cornea 2009; 28: 249–53.