Peter B. Veldman

Standardized DMEK Technique: Reducing Complications Using Prestripped Tissue, Novel Glass Injector, and Sulfur Hexafluoride (SF6) Gas.

Purpose: To report low complication rates in Descemet membrane endothelial keratoplasty (DMEK) using sulfur hexafluoride (SF6) gas, a novel glass injector, and donor tissue prestripped by an eye bank technician. Methods: A standardized technique of DMEK was performed in 80 consecutive Fuchs corneal dystrophy cases using technician-prestripped tissue, a novel glass injector, a modified Yoeruek tap technique, and an SF6 gas (20% concentration) bubble for prolonged tissue support. Twenty-five donors were premarked with an “S” stamp for intraoperative orientation. Surgery was performed by 2 experienced DMEK surgeons and 2 inexperienced cornea fellows. Complications were recorded, and the percent endothelial cell loss was calculated at 6 months postoperatively. Results: There were 5 cases that received an air bubble injection postoperatively (6% rebubble rate). There were 6 grafts that immediately failed, 2 because of excessive surgical trauma, and 4 because of upside-down graft placement documented by optical coherence tomography. None of the 25 cases with an S stamp failed. Recipient corneas cleared quickly with no clinical evidence of toxicity from the SF6 gas bubble, and the grafts experienced a mean endothelial cell loss of 27% at 6 months. Conclusions: Tissue prestripped by an eye bank technician can be safely used for DMEK surgery. SF6 gas for prolonged tissue support may reduce the rebubble rate in DMEK, with no apparent acute toxic effect. An unrecognized upside-down graft was the primary cause of graft failure in this series. Upside-down grafts may be eliminated by the use of donor tissue premarked by the eye bank with an S orientation stamp.

Stamping an S on DMEK Donor Tissue to Prevent Upside-Down Grafts: Laboratory Validation and Detailed Preparation Technique Description.

Purpose: To report endothelial cell loss (ECL) caused by a novel S-stamp preparation technique for Descemet membrane endothelial keratoplasty (DMEK). Methods: Six cadaveric human corneas were prepared for DMEK transplantation using a single standardized technique, including the application of a dry ink gentian violet S-stamp to the stromal side of Descemet membrane. Endothelial cell death was evaluated and quantified using computerized analysis of vital dye staining. Results: ECL caused by the S-stamp was 0.6% (range 0.1%–1.0%), which comprised less than one-tenth of the total ECL caused by our preparation of the DMEK graft from the start to finish, including recovery, prestripping, S-stamping, and trephination (13.7% total ECL, range 9.9%–17.6%). Conclusions: Our novel S-stamp donor tissue preparation technique is intuitive to learn and holds the promise of preventing iatrogenic primary graft failure due to upside-down grafts without causing unacceptable increases in ECL.

Treatment of Fuchs Endothelial Dystrophy by Descemet Stripping Without Endothelial Keratoplasty.

Purpose: To evaluate the effect of deliberate removal of the central Descemet membrane on endothelial function and morphology in patients with Fuchs endothelial dystrophy (FED) and cataract undergoing phacoemulsification. Methods: In this retrospective case series, patients with FED and visually significant cataract underwent phacoemulsification in an academic cornea practice in Boston, MA. Four millimeters of the central Descemet membrane was stripped and removed after intraocular lens insertion. Vision, corneal pachymetry, and confocal imaging of the endothelial anatomy were performed before surgery and at 1, 3, 6, and 12 months after surgery. Patients were classified as fast responders, responders, slow responders, and nonresponders on the basis of postoperative time to resolution of corneal edema with visible central endothelial mosaic. Results: Eleven patients (13 eyes) aged 51 to 91 years were included in the study. No eyes had countable central endothelial cells by confocal imaging before surgery. Preoperative visual acuity ranged from 20/25 to 20/400. All corneas showed stromal and microcystic edema in the area of Descemet stripping at days 1 and 7 after surgery. Four eyes demonstrated resolution of corneal edema with visible central endothelial cell mosaic (range: 410–864 cells/mm2) by postoperative month 1 with visual acuity ranging between 20/25 and 20/40. Four additional eyes demonstrated a similar response by postoperative month 3 and an additional 2 eyes had resolution of corneal edema with an intact central endothelial mosaic at postoperative month 6 or later. Cell counts (range: 428–864 cells/mm2) were maintained in all 10 responders at the last follow-up visit (range: postoperative months 6–24). Final vision ranged from 20/15 to 20/20 in these 10 eyes with the exception of 2 eyes with retinal pathology. Three eyes required endothelial keratoplasty. Conclusions: Repopulation of the central corneal endothelium with corneal deturgescence can occur after deliberate central Descemet stripping in patients with FED who underwent cataract removal. This may offer a novel treatment for patients with FED that could reduce the need for endothelial transplantation. Further studies are needed to delineate the optimal patient population for Descemet stripping because not all patients will respond to this intervention.

Current evidence for topical azithromycin 1% ophthalmic solution in the treatment of blepharitis and blepharitis-associated ocular dryness.

IntroductionBlepharitis, one of the most commonly treated ophthalmic conditions, can also be one of the most frustrating for the managing clinician. Although this is due in part to the chronic nature of the disease, the diversity of therapeutic options and lack of definitive scientific evidence for

Achieving Target Refraction after Cataract Surgery

PURPOSE To evaluate the difference between target and actual refraction after phacoemulsification and intraocular lens implantation at an academic teaching institutions Comprehensive Ophthalmology Service. DESIGN Retrospective study. PARTICIPANTS We examined 1275 eye surgeries for this study. METHODS All consecutive cataract surgeries were included if they were performed by an attending or resident surgeon from January through December 2010. Postoperative refractions were compared with preoperative target refractions. Patients were excluded if they did not have a preoperative target refraction documented or if they did not have a recorded postoperative manifest refraction within 90 days. MAIN OUTCOME MEASURES The main outcome measure was percentage of cases achieving a postoperative spherical equivalent ± 1.0 diopter (D) of target spherical equivalent. RESULTS We performed 1368 cataract surgeries from January through December of 2010. Of these, 1275 (93%) had sufficient information for analysis. Of the included cases, 94% (1196 of 1275) achieved ± 1.0 D of target refraction by 90 days after cataract surgery. CONCLUSIONS This paper establishes a new benchmark for a teaching hospital, where 94% of patients achieved within 1.0 D of target refraction after cataract surgery. The refractive outcomes after cataract surgery at this academic teaching institution were higher than average international benchmarks.

Relationship Between Tissue Unscrolling Time and Endothelial Cell Loss.

Purpose: To assess the relationship between intraoperative unscrolling time of the donor Descemet membrane endothelial keratoplasty (DMEK) tissue and 6-month postoperative endothelial cell loss (ECL), and to determine whether donor age, scroll tightness, and the presence of an S stamp are related to unscrolling time. Methods: Ninety-three consecutive uncomplicated DMEK surgeries performed on eyes with Fuchs endothelial dystrophy using our standardized technique (ie, prestripped tissue with or without a premarked S stamp from our eye bank, overstripping the recipient, Straiko glass injector, no-touch tap technique, and bubble of 20% SF6 gas) were evaluated. Intraoperative unscrolling times and 6-month endothelial cell densities were measured and analyzed. Results: Sixty-nine cases comprised the study cohort. The median unscrolling time was 4 minutes (range: 0.8–17.5 minutes), and the median ECL was 26.9% (range: −4.3% to 80.0%). There was no relationship between unscrolling time and ECL at 6 months by the Pearson correlation coefficient (r = −0.02, P = 0.89). Younger donor age, tighter scrolls, and absence of an S stamp had no correlation with longer unscrolling times (all P > 0.05). Only 2 of 4 cases of iatrogenic primary graft failure had unscrolling times available for analysis; in this limited sample, there was no association between iatrogenic primary graft failure and unscrolling time. Conclusions: Once the DMEK tissue is safely in the anterior chamber, surgeons need not rush the “DMEK dance” because longer unscrolling times may not endanger the endothelium.

Evidence-Based Endothelial Rehabilitation

ABSTRACT Endothelial keratoplasty (EK) has replaced penetrating keratoplasty (PKP) as the preferred surgical therapy for corneal endothelial dysfunction. However, recent nationwide corneal graft registry data showed few advantages to EK relative to PKP with respect to graft survival and visual outcomes. This article compares the published outcomes and complications of EK to those of PKP. EK demonstrates superior spectacle corrected visual outcomes, fast recovery, less graft rejection, and higher patient satisfaction, particularly in studies performed by high-volume surgeons/centers. Endothelial cell loss in EK, while higher at early time points, was equivalent or superior at five-years’ follow-up and graft survival was equivalent to or superior to PKP in these centers/studies. Continued standardization and simplification of EK procedures may allow surgeons who perform a lower volume of EK to achieve results that mirror those of high-volume centers/surgeons and close the potential gap in outcomes demonstrated in the registry data.

Retinal Detachment Associated With Traumatic Chorioretinal Rupture

Traumatic chorioretinal rupture, also known as sclopetaria, is a full-thickness break of the choroid and retina caused by a high-velocity projectile striking or passing adjacent to, but not penetrating, the globe. Previous reports have emphasized that retinal detachment seldom occurs, and observation alone has been the recommended management strategy. However, the authors present herein a series of consecutive patients with retinal detachment associated with sclopetaria and provide a literature review of the topic. They recommend that patients with traumatic chorioretinal rupture be monitored closely for the development of retinal detachment during the first few weeks after the injury.

A Comprehensive Review of Postoperative Management of Descemet’s Membrane Endothelial Keratoplasty

ABSTRACT Introduction: As Descemet’s Membrane Endothelial Keratoplasty (DMEK) continues to gain in popularity, the postoperative management of DMEK surgery is becoming increasingly important, as these management strategies may affect postoperative success rates. Materials and Methods: This article reviews the current evidence for postoperative management in DMEK. Results: There are variable strategies in the postoperative management of DMEK as it relates to postoperative positioning, need for and timing of rebubble, tamponade agent utilized (both primarily and at rebubble), steroid agent and tapering schedule, timing of secondary regraft when required, and postoperative monitoring. Discussion: While a great deal of attention is rightly devoted to developing better surgical techniques for DMEK, we believe it is also crucial to develop a better understanding of and evidence-based best practice in the postoperative management of DMEK, as this may have important implications for outcomes.

Endothelial Keratoplasty: Descemet's Stripping Automated Endothelial Keratoplasty Versus Descemet's Membrane Endothelial Keratoplasty.

Over the previous 15 years, endothelial keratoplasty (EK) has established itself as the standard of care for the treatment of endothelial dysfunction in the absence of significant stromal pathology. EK, primarily of the Descemet’s stripping automated endothelial keratoplasty (DSAEK) variety, supplanted penetrating keratoplasty (PK) in prevalence in the United States for the first time in 2012 and was 35% more common than PK in the 2014 Eye Bank Association of America report (19,294 PK vs. 25,965 EK). Although DSAEK remains the most frequently performed EK procedure, Descemet’s membrane endothelial keratoplasty (DMEK) has gained progressively wider acceptance and the number of DMEK surgeries performed in the United States has quadrupled since 2012, with nearly 3000 cases reported in 2014. This rise in the prevalence of DMEK has been attributed to its faster and superior visual rehabilitation, lower rejection rates, and patient preference for the procedure, when compared with DSAEK. We believe that these advantages, in conjunction with simplified and standardized techniques, will enable DMEK surgery to gain widespread adoption and become the standard of care for the surgical management of uncomplicated endothelial dysfunction. And while the data does support the assertion that DMEK provides superior outcomes relative to DSAEK, it is important to recognize that DSAEK remains indispensable in the management of eyes with certain comorbid conditions, as discussed below.