Pat-Michael Palmiero

Visually Significant and Nonsignificant Complications Arising From Descemet Stripping Automated Endothelial Keratoplasty

PURPOSE To examine the complications encountered after Descemet stripping automated endothelial keratoplasty (DSAEK) at one institution. DESIGN Retrospective case review. METHODS The first 126 consecutive DSAEKs done at the New York Eye and Ear Infirmary from March 1, 2006 to March 1, 2008 were reviewed. A total of 126 eyes of 113 patients underwent DSAEK. All cases were included regardless of outcome. All complications intraoperatively and postoperatively were recorded. RESULTS Graft detachment was the most common complication, occurring in 22 eyes (17.5%); 17 of these (77%) were successfully repositioned. Idiopathic graft failure occurred in 15 eyes (6%). Other visually significant complications included graft rejection (2 eyes), choroidal effusion (2 eyes), epithelial ingrowth (2 eyes), endophthalmitis (1 eye), pupillary block (1 eye), and suture abscess (1 eye). Twenty-four eyes had non-visually significant complications including decentered lenticles, interface fibers, partial peripheral detachments, retained Descemet membrane, and eccentric trephination. CONCLUSIONS While DSAEK is a viable alternative to penetrating keratoplasty, serious complications may still occur postoperatively. While certain rare complications like endophthalmitis, epithelial ingrowth, and suture abscess may affect vision, more common complications such as decentered lenticles and partial peripheral detachments are less likely to affect visual outcome.

Iris Morphologic Changes Related to α1-Adrenergic Receptor Antagonists: Implications for Intraoperative Floppy Iris Syndrome

PURPOSE To identify iris structural alterations associated with intraoperative floppy iris syndrome (IFIS) in patients using systemic alpha(1)-adrenergic receptor antagonists (alpha-1ARA). DESIGN Cross-sectional study. PARTICIPANTS AND CONTROLS Twenty-nine patients with current or past treatment with any systemic alpha-1ARA and 22 untreated controls. METHODS Consecutive eligible patients underwent slit-lamp-adapted optical coherence tomography in a masked fashion under standardized lighting conditions. MAIN OUTCOME MEASURES Iris thickness at the dilator muscle region (DMR; measured at half of the distance between the scleral spur and the pupillary margin) and at the sphincter muscle region (SMR; 0.75 mm from the pupillary margin), the ratio between the DMR/SMR (to compensate for possible intersubject variability), and pupillary diameter. RESULTS Most treated patients were on tamsulosin (27/29). Mean age was similar in study and control groups (70.6+/-7.6 vs 67.1+/-9.1 years; P = 0.061). Photopic pupil diameter was reduced in the study group (2.06+/-0.5 vs 2.5+/-0.6 mm; P = 0.001). The SMR was similar between groups (P = 0.53). Significantly lower values were found in treated subjects for the DMR and the DMR/SMR ratio (P<0.001). These differences remained significant after adjusting for pupil diameter (P<0.001). Multiple regression analysis showed that a longer duration of alpha-1ARA treatment correlated to a reduced DMR/SMR ratio (P = 0.001; r = 0.47). Age and eye color were not significant in this model. CONCLUSIONS Patients using systemic alpha-1ARA have significantly lower values of DMR thickness and DMR/SMR ratio and smaller pupil diameter when compared with age-matched controls. These differences seem to be related to the duration of drug exposure and provide evidence of structural alterations to the iris dilator muscle from this class of agents in IFIS. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found after the references.

Bilateral Descemet membrane detachment after canaloplasty.

We report a case of bilateral Descemet membrane detachment (DMD) after canaloplasty in a 70-year-old Portuguese man with primary open-angle glaucoma. The patient developed bilateral DMD immediately following consecutive (1 week apart) canaloplasty surgery in both eyes. Slitlamp biomicroscopy, gonioscopy, and Fourier-domain optical coherence tomography (FD-OCT) findings are described. On postoperative day 1, in both cases, slitlamp biomicroscopy revealed an unscrolled inferonasal DMD and a clear cornea with deep and quiet anterior chambers. Gonioscopy showed an intact, lightly pigmented, and distended trabecular meshwork with no evidence of suture extrusion. High-resolution FD-OCT revealed a widely dilated canal of Schlemm, trabecular distention, and a retrocorneal hyperreflective membrane corresponding to a DMD. At 3 months, the DMD resolved spontaneously in both eyes. Although DMD is a known complication of canaloplasty, the occurrence of bilateral symmetrically located DMDs in our case suggests a possible anatomical predisposition in addition to factors induced by the surgical technique.

The Use of Postoperative Slit-Lamp Optical Coherence Tomography to Predict Primary Failure in Descemet Stripping Automated Endothelial Keratoplasty

PURPOSE To determine if central donor lenticle thickness as measured by slit-lamp optical coherence tomography (SL OCT; Heidelberg Engineering, Heidelberg, Germany) is predictive of primary donor failure in patients undergoing Descemet stripping automated endothelial keratoplasty (DSAEK). DESIGN Retrospective cross-sectional study. METHODS Eighty-four patients who underwent DSAEK surgery by 2 surgeons (D.C.R. and J.A.S.) were enrolled. At each postoperative visit (postoperative day 1, week 1, month 1, and month 2), an SL OCT scan was obtained. Statistical differences in SL OCT measurements of successful and failed DSAEK procedures were measured using the Student t test. A successful DSAEK surgery was defined as having an anatomically attached, clear recipient corneal stroma and donor lenticle compatible with good vision 2 months after surgery. A failed DSAEK surgery was defined as an attached donor lenticle with SL evidence of corneal edema and thickening visible at 2 months or more. RESULTS Ninety-three eyes of 84 consecutive patients who underwent DSAEK surgery also underwent postoperative SL OCT. After 2 months of follow-up, 82 (88%) procedures were successful and 11 (12%) procedures were failures. The average donor lenticle thickness in successful DSAEK eyes was 314 +/- 128 microm on postoperative day 1 as compared with failed DSAEK eyes, which averaged 532 +/- 259 microm (P = .0013). This was independent regardless of whether the lenticle was attached on the first postoperative visit. Seventy-nine (98%) successful DSAEK eyes had a lenticle thickness of < or = 350 microm at the 1-week visit. All of the failed DSAEK eyes (11 eyes) had a lenticle thickness > or = 350 microm at the 1-week postoperative visit. Statistically significant differences in SL OCT thickness measurements were seen between successful and failed DSAEK cases at all examinations after postoperative week 1. CONCLUSIONS Corneal thickness measurements made with SL OCT are an important predictor of DSAEK failure in both attached and detached lenticles within the first week of surgery. DSAEK lenticle thickness of 350 microm or less at 1 week had a predictability of success of more than 98%.

In vivo imaging of the cornea in a patient with lecithin-cholesterol acyltransferase deficiency.

Purpose: To report high-resolution, in vivo imaging of the cornea in a patient with lecithin-cholesterol acyltransferase (LCAT) deficiency. Methods: A 60-year-old Ecuadorian woman with bilateral corneal opacities and confirmed LCAT deficiency was imaged with Fourier domain optical coherence tomography (FD-OCT) and noncontact Rostock confocal laser scanning microscopy. Results: The FD-OCT revealed a thinned epithelium, homogeneous hyperreflective stroma, and focal disruptions of Bowmans layer. Focal areas of hyperreflectivity with multiple dark striae and reduced and irregular keratocytes were seen throughout the stroma by noncontact Rostock module. The corneal endothelium was normal. Conclusion: New anterior segment in vivo imaging technology permits high-resolutional visualization and monitoring of corneal pathology.

Slit‐lamp‐adapted optical coherence tomography for assessment of an overhanging filtering bleb

Acta Ophthalmol. 2010: 88: 910–911

Noncontact In Vivo Scanning Laser Microscopy of Filtering Blebs

PurposeTo evaluate the ability of a noncontact, prototype scanning laser confocal microscope to image microstructural features of filtering blebs in vivo and to correlate these with the clinical features. MethodsThirty-one blebs of 24 patients underwent noncontact in vivo confocal microscopy using the Rostock Cornea Module of the Heidelberg Retina Tomograph II (50× noncontact Nikon lens, 1-2 μm resolution, field of view: 500×500 μm). Blebs were clinically classified as successful (low, diffuse, microcystic, and hypovascular) (n=22, mean intraocular pressure<20 mm Hg without hypotensive medications) or failed (flat, cicatrized, and nonfiltering) (n=9, mean intraocular pressure>20 mmHg with or without hypotensive medications). Multiple transverse images were taken over the scleral flap at 1 to 2 mm from the limbus. Images were evaluated by 2 observers masked to clinical appearance and function of the bleb. ResultsTransverse images of the successful blebs showed epithelial microcysts (50 to 100 μm) and small-sized to medium-sized (100 to 150 μm) subconjunctival cystic spaces with scattered loose collagen-like networks around the scleral flap. Failed blebs showed diffuse hyperreflective dense stroma, increased and tortuous vascularization, and no cystic spaces. The microscopic findings of all blebs were consistent with previous reports of contact in vivo confocal microscopy. ConclusionsNoncontact in vivo confocal microscopy of filtering blebs correlated with the clinical morphology. This noncontact approach provides information about bleb morphology without the risk of bleb microinjury, leak, or infection. Further study and optimization for imaging surface tissues are needed to improve our understanding of bleb maturation and wound healing.

Iris Morphologic Changes Related to α1-Adrenergic Receptor Antagonists

PURPOSE To identify iris structural alterations associated with intraoperative floppy iris syndrome (IFIS) in patients using systemic alpha(1)-adrenergic receptor antagonists (alpha-1ARA). DESIGN Cross-sectional study. PARTICIPANTS AND CONTROLS Twenty-nine patients with current or past treatment with any systemic alpha-1ARA and 22 untreated controls. METHODS Consecutive eligible patients underwent slit-lamp-adapted optical coherence tomography in a masked fashion under standardized lighting conditions. MAIN OUTCOME MEASURES Iris thickness at the dilator muscle region (DMR; measured at half of the distance between the scleral spur and the pupillary margin) and at the sphincter muscle region (SMR; 0.75 mm from the pupillary margin), the ratio between the DMR/SMR (to compensate for possible intersubject variability), and pupillary diameter. RESULTS Most treated patients were on tamsulosin (27/29). Mean age was similar in study and control groups (70.6+/-7.6 vs 67.1+/-9.1 years; P = 0.061). Photopic pupil diameter was reduced in the study group (2.06+/-0.5 vs 2.5+/-0.6 mm; P = 0.001). The SMR was similar between groups (P = 0.53). Significantly lower values were found in treated subjects for the DMR and the DMR/SMR ratio (P<0.001). These differences remained significant after adjusting for pupil diameter (P<0.001). Multiple regression analysis showed that a longer duration of alpha-1ARA treatment correlated to a reduced DMR/SMR ratio (P = 0.001; r = 0.47). Age and eye color were not significant in this model. CONCLUSIONS Patients using systemic alpha-1ARA have significantly lower values of DMR thickness and DMR/SMR ratio and smaller pupil diameter when compared with age-matched controls. These differences seem to be related to the duration of drug exposure and provide evidence of structural alterations to the iris dilator muscle from this class of agents in IFIS. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found after the references.

Asymmetric progressive glaucomatous optic neuropathy in a patient with a rare developmental variant of the ophthalmic artery.

PurposeTo report a case of a developmental anatomic finding of the ophthalmic artery (OA) in a patient with ipsilateral progressive advanced glaucomatous optic neuropathy and visual field loss. MethodsA 59-year-old Asian man with normal tension glaucoma had progressive asymmetric visual field loss OD. Magnetic resonance imaging and angiography of the orbit were performed because of continued progression despite medical and surgical intervention. ResultsMagnetic resonance angiography revealed an anomalous OA, lateral to the carotid artery and emanating from a branch of the middle meningeal artery. ConclusionOA anomalies should be added to the differential diagnosis of risk factors for unilateral progressive glaucomatous optic neuropathy, and neuroradiologic imaging should be considered to detect such anatomic variants.

Imaging of descemet membrane detachment after trabeculectomy using slit-lamp-adapted optical coherence tomography.

PurposeTo report the use of slit-lamp–adapted optical coherence tomography (SL-OCT) in imaging 2 patients with Descemet membrane detachment following anterior chamber reformation after trabeculectomy. MethodsTwo patients, with leaking and overfiltering blebs, respectively, developed Descemet detachments after reformation of flat anterior chambers with viscoelastics. Slit-lamp biomicroscopy and SL-OCT were used to diagnose and monitor posttreatment outcome. ResultsBiomicroscopic evaluation and SL-OCT imaging of the cornea revealed a Descemet detachment in both cases. One patient underwent intracameral air injection. Follow-up SL-OCT imaging revealed reattachment of Descemet membrane and reduced corneal thickness. ConclusionsSL-OCT can be used to document and follow postsurgical detachment of Descemet membrane.