Roni M. Shtein

Descemet's Stripping Endothelial Keratoplasty: Safety and Outcomes

OBJECTIVE To review the published literature on safety and outcomes of Descemets stripping endothelial keratoplasty (DSEK) for the surgical treatment of endothelial diseases of the cornea. DESIGN Peer-reviewed literature searches were conducted in PubMed and the Cochrane Library with the most recent search in February 2009. The searches yielded 2118 citations in English-language journals. The abstracts of these articles were reviewed and 131 articles were selected for possible clinical relevance, of which 34 were determined to be relevant to the assessment objectives. RESULTS The most common complications from DSEK among reviewed reports included posterior graft dislocations (mean, 14%; range, 0%-82%), followed by endothelial graft rejection (mean, 10%; range, 0%-45%), primary graft failure (mean, 5%; range, 0%-29%), and iatrogenic glaucoma (mean, 3%; range, 0%-15%). Average endothelial cell loss as measured by specular microscopy ranged from 25% to 54%, with an average cell loss of 37% at 6 months, and from 24% to 61%, with an average cell loss of 42% at 12 months. The average best-corrected Snellen visual acuity (mean, 9 months; range, 3-21 months) ranged from 20/34 to 20/66. A review of postoperative refractive results found induced hyperopia ranging from 0.7 to 1.5 diopters (D; mean, 1.1 D), with minimal induced astigmatism ranging from -0.4 to 0.6 D and a mean refractive shift of 0.11 D. A review of graft survival found that clear grafts at 1 year ranged from 55% to 100% (mean, 94%). CONCLUSIONS The evidence reviewed is supportive of DSEK being a safe and effective treatment for endothelial diseases of the cornea. In terms of surgical risks, complication rates, graft survival (clarity), visual acuity, and endothelial cell loss, DSEK appears similar to penetrating keratoplasty (PK). It seems to be superior to PK in terms of earlier visual recovery, refractive stability, postoperative refractive outcomes, wound and suture-related complications, and intraoperative and late suprachoroidal hemorrhage risk. The most common complications of DSEK do not appear to be detrimental to the ultimate vision recovery in most cases. Long-term endothelial cell survival and the risk of late endothelial rejection are beyond the scope of this assessment. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found after the references.

Deep Anterior Lamellar Keratoplasty as an Alternative to Penetrating Keratoplasty: A Report by the American Academy of Ophthalmology

OBJECTIVE To review the published literature on deep anterior lamellar keratoplasty (DALK) to compare DALK with penetrating keratoplasty (PK) for the outcomes of best spectacle-corrected visual acuity (BSCVA), refractive error, immune graft rejection, and graft survival. METHODS Searches of the peer-reviewed literature were conducted in the PubMed and the Cochrane Library databases. The searches were limited to citations starting in 1997, and the most recent search was in May 2009. The searches yielded 1024 citations in English-language journals. The abstracts of these articles were reviewed, and 162 articles were selected for possible clinical relevance, of which 55 were determined to be relevant to the assessment objective. RESULTS Eleven DALK/PK comparative studies (level II and level III evidence) were identified that compared the results of DALK and PK procedures directly; they included 481 DALK eyes and 501 PK eyes. Of those studies reporting vision and refractive data, there was no significant difference in BSCVA between the 2 groups in 9 of the studies. There was no significant difference in spheroequivalent refraction in 6 of the studies, nor was there a significant difference in postoperative astigmatism in 9 of the studies, although the range of astigmatism was often large for both groups. Endothelial cell density (ECD) stabilized within 6 months after surgery in DALK eyes. Endothelial cell density values were higher in the DALK groups in all studies at study completion, and, in general, the ECD differences between DALK and PK groups were significant at all time points at 6 months or longer after surgery for all of the studies reporting data. CONCLUSIONS On the basis of level II evidence in 1 study and level III evidence in 10 studies, DALK is equivalent to PK for the outcome measure of BSCVA, particularly if the surgical technique yields minimal residual host stromal thickness. There is no advantage to DALK for refractive error outcomes. Although improved graft survival in DALK has yet to be demonstrated, postoperative data indicate that DALK is superior to PK for preservation of ECD. Endothelial immune graft rejection cannot occur after DALK, which may simplify long-term management of DALK eyes compared with PK eyes. As an extraocular procedure, DALK has important theoretic safety advantages, and it is a good option for visual rehabilitation of corneal disease in patients whose endothelium is not compromised.

Options and Adjuvants in Surgery for Pterygium: A Report by the American Academy of Ophthalmology

OBJECTIVE To assess the outcomes and safety of current surgical options and adjuvants in the treatment of primary and recurrent pterygium. METHODS Literature searches of the PubMed and the Cochrane Library databases were last conducted in January 2011 using keywords and were restricted to randomized controlled trials reporting on surgical intervention for pterygium. The searches were limited to articles published in English and yielded 120 citations. Citation abstracts, and if necessary the full text, were reviewed to identify randomized controlled trials that reported recurrence as an outcome measure and had a mean follow-up of at least 6 months. Fifty-one studies comparing bare sclera excision, conjunctival or limbal autograft, intraoperative mitomycin C, postoperative mitomycin C, and amniotic membrane transplantation for primary and recurrent pterygia fit these inclusion criteria. RESULTS Four studies demonstrated that the conjunctival or limbal autograft procedure is more efficacious than amniotic membrane placement. Use of conjunctival or limbal autografts or mitomycin C during or after pterygium excision reduced recurrence compared with bare sclera excision alone in most studies of primary or recurrent pterygium. The outcomes of conjunctival or limbal autograft were similar to outcomes for intraoperative mitomycin C in the few studies that directly compared the 2 techniques. There is evidence that increased concentration and duration of exposure to intraoperative mitomycin C is associated with increased efficacy. Of the adjuvants studied, only mitomycin C was associated with vision-threatening complications, including scleral thinning, ulceration, and delayed conjunctival epithelialization; there is some evidence of increasing complications with increased concentration and duration of exposure. There is conflicting evidence as to whether increasing age is protective against recurrence, but the morphologic features of the pterygium were shown to affect the recurrence rate. CONCLUSIONS Evidence indicates that bare sclera excision of pterygium results in a significantly higher recurrence rate than excision accompanied by use of certain adjuvants. Conjunctival or limbal autograft was superior to amniotic membrane graft surgery in reducing the rate of pterygium recurrence. Among other adjuvants, there is evidence that mitomycin C and conjunctival or limbal autografts reduce the recurrence rate after surgical excision of a pterygium. Furthermore, the data indicate that using a combination of conjunctival or limbal autograft with mitomycin C further reduces the recurrence rate after pterygium excision compared with conjunctival or limbal autograft or mitomycin C alone. Additional studies are necessary to determine the long-term effects, optimal route of administration, and dose and duration of treatment for mitomycin C. Factors such as availability of resources, primary or recurrent status of pterygium, age of patient, and surgeon or patient preference may influence the surgeons choice of adjuvant because there are insufficient data to recommend a specific adjuvant as superior. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found after the references.

Dry eyes and corneal sensation after laser in situ keratomileusis with femtosecond laser flap creation Effect of hinge position, hinge angle, and flap thickness.

PURPOSE: To determine whether corneal sensation and dry‐eye signs and symptoms after myopic laser in situ keratomileusis (LASIK) surgery with a femtosecond laser are affected by varying hinge position, hinge angle, or flap thickness. SETTING: University‐based academic practice, Ann Arbor, Michigan, USA. METHODS: This prospective randomized contralateral‐eye study evaluated eyes after bilateral myopic LASIK with a femtosecond laser (IntraLase). Superior and temporal hinge positions, 45‐degree and 90‐degree hinge angles, and 100 μm and 130 μm corneal flap thicknesses were compared. Postoperative follow‐up at 1 week and 1, 3, 6, and 12 months included central Cochet‐Bonnet esthesiometry, the Ocular Surface Disease Index questionnaire, a Schirmer test with anesthesia, tear breakup time (TBUT), corneal fluorescein staining, and conjunctival lissamine green staining. RESULTS: The study evaluated 190 consecutive eyes (95 patients). Corneal sensation was reduced at all postoperative visits, with improvement over 12 months (P<.001). There was no difference in corneal sensation between the different hinge positions, angles, or flap thicknesses at any time point. The overall ocular surface disease index score was increased at 1 week, 1 month, and 3 months (P<.0001, P<.0001, and P = .046, respectively). The percentage of patients with a TBUT longer than 10 seconds was significantly lower at 1 week and 1 month (P<.0001). CONCLUSIONS: Dry‐eye syndrome after myopic LASIK with a femtosecond laser was mild and improved after 3 months. Corneal flap hinge position, hinge angle, and thickness had no effect on corneal sensation or dry‐eye syndrome.

Femtosecond laser-assisted corneal surgery.

Purpose of review The femtosecond laser has potentially improved the safety and precision of creating corneal flaps in laser in situ keratomileusis (LASIK). This review focuses on recent advances in applying femtosecond laser technology to other corneal procedures. Recent findings The femtosecond laser is capable of cutting tissue at various depths and patterns with minimal collateral tissue injury. The laser can now be used to perform corneal pockets for ring segments, arcuate wedge-shaped resection in correction of high astigmatism, lamellar dissections in anterior lamellar keratoplasty, donor tissue preparation in Descemets stripping endothelial keratoplasty, and shaped full-thickness keratoplasty. Summary Femtosecond laser-assisted corneal surgery may provide a more precise and safer approach to corneal surgery.

Post-LASIK dry eye

Laser-assisted in situ keratomileusis (LASIK) is a frequently performed corneal refractive surgery with excellent refractive outcomes. The most common complication of LASIK is dry eyes, with virtually all patients developing some degree of dryness in the immediate postoperative period. Identifying preoperative dry eyes, and conscientious attention and treatment in the perioperative time period, can lead to enhanced patient satisfaction and more accurate visual outcomes. Improved understanding of the development of dry eyes after LASIK will advance our understanding of the complex pathophysiology of dry eye disease.

Effect of hinge position on corneal sensation and dry eye after laser in situ keratomileusis using a femtosecond laser

PURPOSE: To determine whether hinge position has an effect on corneal sensation and dry‐eye symptoms after myopic laser in situ keratomileusis (LASIK) performed with the IntraLase femtosecond laser (IntraLase Corp.). SETTING: University‐based academic practice, Ann Arbor, Michigan, USA. METHODS: Sixty‐six consecutive eyes of 33 patients were prospectively evaluated in a randomized contralateral‐eye study to compare the difference between superior‐hinge and temporal‐hinge locations after bilateral myopic LASIK with the IntraLase femtosecond laser. Central Cochet‐Bonnet esthesiometry, the Ocular Surface Disease Index (OSDI) questionnaire, Schirmer test with anesthesia, tear breakup time (TBUT), corneal fluorescein, and conjunctival lissamine green staining were evaluated preoperatively as well as 1 week and 1, 3, 6, and 12 months after surgery. RESULTS: Corneal sensation was reduced with both superior‐hinged and temporal‐hinged LASIK flaps 1 week and 1, 3, 6, and 12 months after surgery (P<.0001). There was no difference in corneal sensation between superior‐hinged and temporal‐hinged flaps at any time point. The OSDI score was increased in 22.6% of patients at 1 week and 21.9% at 1 month (P<.00001), and corneal fluorescein staining was increased in 18% at 1 week. There were no differences in the OSDI, Schirmer with anesthesia, TBUT, corneal fluorescein, or conjunctival lissamine green staining when preoperative values and hinge location were compared. CONCLUSIONS: Mild dry‐eye disease was present early after myopic LASIK with the IntraLase laser. Hinge position had no effect on central corneal sensation or dry‐eye disease.

Boston Keratoprosthesis: Outcomes and Complications: A Report by the American Academy of Ophthalmology

OBJECTIVE To review the published literature on safety and outcomes of the Boston type I keratoprosthesis (BI-KPro) for the surgical treatment of corneal opacification not amenable to human cadaveric corneal transplantation. METHODS Searches of peer-reviewed literature were conducted in PubMed and the Cochrane Library in December 2012, July 2013, and January 2014 without date restrictions. The searches were limited to studies published in English and yielded 587 citations. The abstracts of these articles were reviewed, 48 articles were selected for possible clinical relevance, and 22 were determined to be relevant for the assessment objectives. Nine studies were rated as level II evidence and 13 studies were rated as level III evidence. Excluded were level III evidence, case reports, review articles, letters, editorials, and case series with fewer than 25 eyes. RESULTS In 9 articles, a best-corrected Snellen visual acuity (BCSVA) of 20/200 or better occurred in 45% to 89% of eyes. Five articles described a BCSVA of 20/50 or better in 43% to 69% of eyes, and 4 articles found a BCSVA of 20/40 or better in 11% to 39% of eyes. Retention rates of the BI-KPro ranged from 65% to 100%. Reasons for loss of vision after BI-KPro implantation most commonly included corneal melts resulting from exposure keratopathy, endophthalmitis, and infectious keratitis or corneal ulceration. The 2 most common complications after surgery were retroprosthetic membrane formation (range, 1.0%-65.0%; mean ± standard deviation [SD], 30.0±19.0%) and elevated intraocular pressure (range, 2.4%-64.0%; mean ± SD, 27.5±18.1%). The 2 most common posterior segment complications were endophthalmitis (range, 0%-12.5%; mean ± SD, 4.6±4.6%) and vitritis (range, 0%-14.5%; mean ± SD, 5.6±4.7%). CONCLUSIONS The reviewed articles on BI-KPro use suggest that the device improves vision in cases of severe corneal opacification that were not amenable to corneal transplantation using human cadaveric keratoplasty techniques. A number of severe anterior and posterior segment complications can develop as follow-up continues, making ongoing close observation paramount for patients undergoing this surgery. These complications include infection, device extrusion, and permanent vision loss.

Treatment of ocular graft-versus-host disease with topical cyclosporine 0.05%.

Purpose: To evaluate the efficacy of topical cyclosporine-A 0.05% (CsA) in the treatment of dry eye syndrome in ocular graft-versus-host disease after bone marrow transplantation (BMT) of hematopoietic stem cells. Methods: One-hundred five patients were enrolled in a retrospective, comparative, interventional case series. Eighty-one patients received topical CsA starting 1 month before BMT (treatment group), and 24 patients did not receive CsA until at least 6 months after the transplantation (control group). Mean follow-up time was 17.5 ± 11.0 months (range: 6.0-49.0 months). Clinical history, ocular surface disease index questionnaire, slit-lamp examination, lissamine green and fluorescein staining of the ocular surface, tear breakup time, and Schirmer test with topical anesthesia were obtained to create a composite dry eye-grading score. Results: Dry eye symptoms were significantly more severe in the control group at 3 months, 1 year, and 2 years (P < 0.05). There was no correlation with type of stem cell transplant (related vs. unrelated donor), presenting indication for BMT, or concurrent systemic immunosuppressive medications. Conclusions: Pre-BMT initiation of topical CsA may reduce the inflammatory response in the lacrimal glands that may be responsible for the development of post-BMT keratitis sicca.

Trends in corneal transplantation: indications and techniques.

Purpose of review To describe trends in corneal transplantation surgery, including indications for surgery, evolution of lamellar keratoplasty, current surgical techniques, and future directions. Recent findings Over the past decade, anterior and posterior lamellar keratoplasty have begun to supplant penetrating keratoplasty. Surgical techniques continue to change and improve outcomes. In recent years, Descemet membrane endothelial keratoplasty (DMEK) has gained interest as it eliminates the corneal stromal interface, which may limit visual acuity after Descemet stripping automated endothelial keratoplasty. Despite the promising results with improved visual acuity and decreased rejection, the technical challenges associated with DMEK have limited widespread acceptance. With technical refinements and more eye banks providing precut tissue for both Descemet stripping automated endothelial keratoplasty and DMEK, it is likely both procedures will continue to increase over time. Summary Corneal transplantation has evolved rapidly over the past decade, from full-thickness penetrating keratoplasty towards lamellar keratoplasty to only remove and replace damaged layers of the cornea. Achieving minimal induced astigmatism with excellent visual acuity remains a challenge in corneal transplantation. Further refinements in surgical technique may help improve technical challenges and visual outcomes. In this article, we review changing trends in corneal transplantation and highlight developing medical treatments that may be available in the future.