Ruth Lapid-Gortzak

Posterior lamellar keratoplasty using descemetorhexis and organ-cultured donor corneal tissue (Melles technique)

Purpose: To report the clinical results of posterior lamellar keratoplasty (PLK) using predissected organ-cultured donor corneal tissue implanted after stripping of the Descemet membrane. Methods: Twenty-two eyes of 22 patients in whom a PLK procedure was performed for pseudophakic bullous keratopathy and/or Fuchs endothelial dystrophy were evaluated. In all eyes, the recipient Descemet membrane was excised by performing a descemetorhexis. Just after harvesting the donor tissue, each cornea had a posterior lamellar dissection made at approximately 80% stromal depth, and each cornea was preserved in an organ culture system for 10 to 21 days. During surgery, a posterior lamellar disk was trephinated from the predissected donor cornea and inserted through a 5.0-mm scleral incision into the anterior chamber of the recipient by folding the donor. Specular microscopy was performed at 6, 12, and 18 months to measure the endothelial cell density. Results: In 3 eyes (14%), the posterior donor disk did not attach to the recipient posterior stroma, so a penetrating keratoplasty was performed in a secondary procedure. The transplants in the remaining 19 eyes cleared and maintained clarity throughout the follow-up period. In these eyes, best corrected visual acuity (BCVA) ranged from 0.25 to 1.0 up to 27 months of follow-up. Postoperative astigmatism averaged 1.7 ± 1.0 D. Endothelial cell density averaged 1650 ± 390 cells/mm2 at 6 months, 1560 ± 350 cells/mm2 at 12 months, and 1500 ± 430 cells/mm2 at 24 months. Two eyes developed mild interface haze. Conclusion: PLK can be performed using an organ-cultured donor posterior disk. Visual rehabilitation may be slower than in PLK with fresh donor tissue.

Quality of Vision in Patients With Fuchs Endothelial Dystrophy and After Descemet Stripping Endothelial Keratoplasty

OBJECTIVE To evaluate the quality of vision (visual acuity and straylight) in patients with Fuchs dystrophy and the improvement in visual quality after Descemet stripping endothelial keratoplasty (DSEK). METHODS There was an observational case series (Amsterdam group) and a prospective interventional case series (Mayo group). Corrected distance visual acuity (CDVA), straylight, and corneal thickness were measured in patients with phakic and pseudophakic eyes with Fuchs dystrophy recruited at the Academic Medical Center, Amsterdam, the Netherlands (99 eyes), and at Mayo Clinic, Rochester, Minnesota (48 eyes). The Mayo group was also examined at 1, 3, 6, and 12 months after DSEK; all these eyes were rendered pseudophakic during DSEK. RESULTS Eyes with Fuchs dystrophy had decreased CDVA (mean [SD], 0.42 [0.26] logMAR; Snellen equivalent 20/53) and increased straylight (mean [SD], 1.54 [0.24] logarithm of the straylight parameter) compared with normal eyes. Younger patients were affected more by increased straylight than by decreased CDVA. Corrected distance visual acuity (r = 0.26; P = .003; n = 135) and straylight (r = 0.26; P = .003; n = 133) were correlated with corneal thickness. Corrected distance visual acuity and straylight improved at all postoperative examinations (P < .001), and improvement in straylight from before DSEK to 12 months after DSEK correlated with recipient age (r = -0.43; P = .01; n = 33). Improvement in straylight was more predictable than that of CDVA and was associated with preoperative straylight more than 1.33 logarithm of the straylight parameter. CONCLUSIONS Quality of vision is severely impaired in patients with Fuchs dystrophy and improves significantly after DSEK. Straylight improves more in younger than in older eyes after DSEK. Preoperative straylight can be a useful clinical metric to predict postoperative improvement, especially in cases where preoperative visual acuity is close to 20/20.

Comparison of a new-generation sectorial addition multifocal intraocular lens and a diffractive apodized multifocal intraocular lens.

PURPOSE: To compare visual, refractive, and satisfactory outcomes between a new‐generation sectorial addition multifocal intraocular lens (IOL) (Lentis Mplus LS‐312; study group) and a diffractive apodized multifocal IOL (Restor SN6AD1; control group). SETTING: Private practice, Driebergen, and Department of Ophthalmology, Academic Medical Center, Amsterdam, The Netherlands. DESIGN: Comparative case series. METHODS: Refractive and visual outcomes at near and distance, patient satisfaction, and dysphotopsia scores were recorded 3, 6, and 12 months postoperatively. RESULTS: The study group comprised 90 eyes and the control group, 143 eyes. Three months postoperatively, the mean uncorrected distance visual acuity (UDVA) was not statistically significantly different between the study group and the control group (0.04 ± 0.15 logMAR [SD] versus 0.06 ± 0.25 logMAR). The control group had significantly better uncorrected near visual acuity than the study group at 30 cm (0.05 ± 0.14 logMAR versus 0.15 ± 0.08 logMAR) and 40 cm (0.05 ± 0.14 versus 0.16 ± 0.21) (P<.01 and P<.03, respectively). Patients in the control group were more satisfied with their vision (P<.001). Dissatisfaction was related to younger age at surgery and male sex (P<.0001 and P<.033 respectively). Dysphotopsia occurred in approximately 18% of cases in both groups. CONCLUSIONS: The new sectorial addition multifocal IOL performed comparably to the diffractive apodized multifocal IOL in terms of UDVA and the presence of dysphotopsia. The diffractive apodized multifocal IOL performed better at 30 cm and 40 cm reading distances and had higher patient satisfaction. Financial Disclosure: Dr. Lapid‐Gortzak has received speaker’s fees from Alcon, Simovision, Oculentis, and Medtechnika. Dr. Lapid‐Gortzak and Dr. van der Meulen have received an unrestricted research grant from Oculentis. Dr. van Velthoven has received speaker’s fees from Novartis (Netherlands). Drs. van der Linden, Nieuwendaal, and Mourits have no financial or proprietary interest in any material or method mentioned.

Thickness measurements of donor posterior disks after descemet stripping endothelial keratoplasty with anterior segment optical coherence tomography.

Purpose: To evaluate donor posterior disk thickness measured with anterior segment optical coherence tomography after Descemet stripping endothelial keratoplasty. Methods: Fifteen patients (17 eyes) after Descemet stripping endothelial keratoplasty, using manually dissected donor posterior disks, were measured with the Visante anterior segment optical coherence tomography (Carl Zeiss Meditec Inc, Dublin, CA). Optical coherence tomography scans were made in a radial pattern, 45 degrees apart, starting in the horizontal axis. Thickness measurements of the donor posterior disks were taken centrally and at fixed radii toward the periphery and were correlated to postoperative change in spherical equivalent (SE), best-corrected visual acuity (BCVA, in Snellen), and improvement in BCVA. Results: Median BCVA was 20/30 (range 20/60-20/20) postoperatively. Median postoperative improvement in BCVA was 4 lines (range 1-11). Median follow-up time was 15.5 months (range 6-32 months). Median postoperative change in SE was −0.25 diopters (range −4.25 to +3.00 diopters). Median central disk thickness was 128.3 μm (range 55-181 μm) and increased significantly toward the periphery: median disk thickness at the 1.5 mm radius was 140.8 μm (range 72-199 μm) and at the 3.0 mm radius was 161.5 μm (range 102-245 μm). No correlation was found between (central) donor disk thickness and postoperative BCVA or change in SE. A nonstatistically significant trend was seen toward more improvement in BCVA with thinner donor disks. Conclusions: Optical coherence tomography measurements of the manually dissected donor posterior disk showed significant variation in thickness, without a statistically significant effect on postoperative BCVA or improvement thereof. Central thickness varied significantly from the peripheral thickness within donor posterior disk.

Straylight measurements in contact lens wear.

Purpose: (1) To quantify the effect of contact lens wear on straylight in rigid and soft contact lens wearers and (2) to relate findings to morphological changes and subjective complaints. Methods: Straylight was measured using the Oculus C-Quant during contact lens wear and after contact lens removal in 30 rigid contact lens wearers and 30 soft contact lens wearers. Semi-quantitative (0-4) slit-lamp grading of anterior segment changes using Efron grading scales and contact lens characteristics were performed. Subjects answered a straylight questionnaire. Results: Soft contact lens wearers had a mean straylight of logarithmic value of the straylight parameter [log(s)] = 0.934 during contact lens wear and after contact lens removal [comparable to log(s) = 0.938 of age-matched normal eyes]. Rigid contact lens wearers had a mean straylight during contact lens wear of log(s) = 1.167. After contact lens removal, log(s) significantly decreased to 0.997 (P < 0.01). Straylight values with rigid contact lenses were strongly increased (P < 0.001) compared with age-matched normal eyes; after contact lens removal, these values decreased but remained elevated. Straylight in rigid contact lens wearers correlated with the amount of deposits on the contact lens (P < 0.01) but not with other variables of the contact lens score. The questionnaire showed more straylight complaints in rigid contact lens wearers than in soft contact lens wearers (P < 0.01). Conclusions: Rigid contact lens wear leads to increased straylight during contact lens wear and after contact lens removal. This may be because of subclinical effects of contact lens wear on the cornea and is not seen in soft contact lens wearers.

Herpes simplex virus keratitis after laser in situ keratomileusis.

PURPOSE To report two cases of herpes simplex virus (HSV) keratitis after laser in situ keratomileusis (LASIK). METHODS Interventional small case series. Two patients underwent uneventful LASIK. History of herpes labialis in one patient and herpetic eye disease > 10 years prior to intervention in the other patient was reported. Both patients developed stromal herpetic keratitis 6 weeks and 2 years after the procedure, respectively. RESULTS Treatment consisting of topical steroid drops and topical and systemic antiviral therapy was administered. Recurrences of the herpetic keratitis were seen after tapering of the topical steroids; four and three recurrences were observed, respectively. Final visual acuity was > 6/9 in both cases. CONCLUSIONS Herpetic keratitis after LASIK is an uncommon, possibly under-reported, entity. Even patients without history of herpetic eye disease can present with this complication. Oral antiviral prophylaxis may be appropriate when performing LASIK on patients with a history of ocular or systemic HSV infection.

Straylight measurements in laser in situ keratomileusis and laser-assisted subepithelial keratectomy for myopia

PURPOSE: To compare straylight values before and 3 months after laser in situ keratomileusis (LASIK) and laser‐assisted subepithelial keratectomy (LASEK) and to analyze the causes of any change. SETTING: Private refractive surgery clinic, Driebergen, The Netherlands. METHODS: Straylight was measured before and after LASIK or LASEK with a C‐Quant straylight meter; values were recorded as the straylight parameter log(s). Main outcome measures were the difference between postoperative and preoperative straylight values and factors causing a difference between the values. RESULTS: The study evaluated 102 eyes having LASIK and 137 eyes having LASEK. On average, there was significant improvement in straylight values postoperatively in both groups. The mean decrease was −0.016 log(s) in the LASIK group and −0.026 log(s) in the LASEK group. Nonparametric testing (sign test) showed that the improvement in straylight was statistically significant in more than 50% of eyes in both groups. Straylight improved in 62 eyes in the LASIK group (P<.001) and 78 eyes in the LASEK group (P<.02) and deteriorated in 35 eyes and 58 eyes, respectively. There was an increase in straylight in 17 eyes (7.1%). Clinical correlations were found in some eyes that had increased postoperative straylight values. CONCLUSION: On average, straylight values 3 months after LASIK and LASEK were slightly decreased from baseline values. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned. Additional disclosures are found in the footnotes.

Calcification of a hydrophilic acrylic intraocular lens after Descemet-stripping endothelial keratoplasty: case report and laboratory analyses.

We describe the case of an 83-year-old woman who had uneventful phacoemulsification with implantation of a tripod hydrophilic acrylic intraocular lens (IOL). Because of postoperative corneal decompensation, 2 Descemet-stripping endothelial keratoplasty (DSEK) procedures were performed within 2 years. After the second procedure, the graft was not well attached, requiring an intracameral injection of air on day 3. Approximately 9 months later, opacification was observed on the anterior surface of the IOL, with a significant decrease in visual acuity. The IOL was explanted within the capsular bag. Laboratory analyses revealed granular deposits densely distributed in a round pattern within the margins of the capsulorhexis. Granules were located at the anterior surface/subsurface of the IOL and stained positive for calcium (alizarin red and von Kossa method). Scheimpflug photography revealed high levels of light scattering from the opacified area. Surgeons should be aware of possible localized calcification following DSEK procedures in pseudophakic patients with hydrophilic acrylic IOLs.

Contributions of the Capsulorrhexis to Straylight

OBJECTIVES To quantify the effect of the capsulorrhexis on straylight and to determine optimal capsulorrhexis size. METHODS Fifty-six pseudophakic eyes with intact capsulorrhexis were included in the study. Straylight was measured with a straylight meter before and after pupil dilation. Capsulorrhexis and pupil diameter were measured and opacity of the anterior capsule was graded (on a scale of 0-5) with the slitlamp. Capsulorrhexis size and opacity were compared with the difference in straylight values between natural and dilated pupils. RESULTS The mean capsulorrhexis diameter was 4.5 mm (range, 2.9-6.2 mm). Most anterior capsular rims were opaque in the area of contact with the intraocular lens (62.5% higher than grade 1). Mean straylight before pupil dilation was log(s)=1.25 (range, 0.68-2.13), which increased to 1.46 (range, 0.88-2.22) after pupil dilation, which corresponds to a 62% increase (P <.001). The effect of capsulorrhexis size and opacity on the increase in straylight in scotopic conditions can be quantified by the following formula: Deltas = 19 x (grading of anterior capsular rim) x (fraction of pupil area covered by rhexis). CONCLUSIONS The influence of size and opacity of the capsulorrhexis via straylight is described in a quantitative model. Capsulorrhexis size must be greater than 4 mm to prevent functional problems at night.

Correlation of Straylight and Visual Acuity in Long-Term Follow-up of Manual Descemet Stripping Endothelial Keratoplasty

Purpose Long-term quality of vision after Descemet stripping endothelial keratoplasty (DSEK) was evaluated and correlated with corneal characteristics and subjective complaints. Methods Thirty-four eyes were examined; patients had a single visit 6 to 64 months after DSEK for Fuchs dystrophy. Best-corrected distance acuity (BCDA) and straylight were analyzed. To better evaluate long-term postoperative BCDA changes, longitudinal data were used from earlier visits. Corneal thickness was measured with the Visante anterior segment optical coherence tomography. Interface, stromal, and endothelial haze were semiquantitatively graded using the slit lamp. Vision-related quality of life was evaluated with the 39-item National Eye Institute Visual Function Questionnaire and a straylight questionnaire. Correlation analysis comparing corneal characteristics with visual quality was performed. Results Mean postoperative time was 1027 ± 453 days. Mean BCDA at this time was 0.33 ± 0.19 logarithm of the minimal angle of resolution. BCDA remained stable with long-term postoperative follow-up. Straylight averaged 1.47 ± 0.19, on average 0.12 log units higher than normal for age-related pseudophakic eyes (P < 0.001). BCDA correlated with corneal haze (r = 0.50), whereas straylight showed a nonsignificant association (P = 0.12). Neither BCDA nor straylight correlated with corneal thickness. Mean Visual Function Questionnaire 39 score was 77/100, and mean score of the straylight questionnaire was 46/100. Conclusion Quality of vision after DSEK does not return to normal levels of age-matched pseudophakic eyes, with decreased BCDA and increased straylight. Questionnaire scores indicate mild (Visual Function Questionnaire 39) to moderate (straylight) subjective visual impairment. Corneal thickness and haze do not offer an adequate explanation for the decreased visual quality.