Suxia Li

Risk Factors, Clinical Features, and Outcomes of Recurrent Fungal Keratitis after Corneal Transplantation

PURPOSE To study the risk factors, clinical features, and treatment of recurrent fungal keratitis after corneal transplantation. DESIGN Retrospective, interventional case series. PARTICIPANTS Eight hundred ninety-nine patients (eyes) with fungal keratitis who underwent corneal transplantation at the Shandong Eye Institute between January 2000 and October 2008. Six hundred fourteen patients underwent penetrating keratoplasty (PK) and 285 patients underwent lamellar keratoplasty (LK). METHODS All patients failed to respond to topical and systemic antifungal drugs treatment before corneal transplantation. A trephine that was 0.5 mm larger in diameter than the infection area was used during PK or LK. Medical records of each patient were reviewed retrospectively. The species of pathogenetic fungi causing recurrence were analyzed. The clinical features, including recurrence time, position, symptom, and physical signs, were summarized. Based on clinical features, appropriate topical and systemic antifungal treatment was determined for all patients; some patients also received combined subconjunctival or intracameral injection of fluconazole. If there was treatment failure, a conjunctival flap or keratoplasty was performed. MAIN OUTCOME MEASURES Species of pathogenetic fungi, clinical features, and apparent therapeutic effects. RESULTS Fifty-seven patients (6.34%) experienced recurrence after corneal transplantation. There was no difference between PK (6.79%) and LK (5.96%) in recurrence rate (P = 0.883). A higher rate of recurrences was found in those with preoperative hypopyon (10.90%), corneal perforation (12.00%), corneal infection expanding to limbus (20.69%), or lens infection with extracapsular cataract extraction (50%; P<0.05). The 3 main kinds of recurrence were: (1) recurrent infection from recipient bed to graft, and once recurrent infection invaded the graft, the inflammation progressed more rapidly; (2) white mushroom-shaped hypopyon with anterior chamber recurrence; (3) infection in the posterior chamber and vitreous opacity on posterior segment recurrence. Location of recurrence was: recipient bed (70.18%), anterior chamber (7.02%), and posterior segment (22.81%). The overall cure rate was 82.46%, which included drug therapy (28.07%) and surgical treatment (54.39%). CONCLUSIONS Hypopyon, corneal perforation, corneal infection expanding to limbus and lens infection are major risk factors for recurrence of fungal keratitis after corneal transplantation. Based on the clinical features of recurrence, appropriate treatment options can help to control the recurrent infection.

Penetrating keratoplasty with small-diameter and glycerin-cryopreserved grafts for eccentric corneal perforations.

Purpose: To report the outcome of penetrating keratoplasty with small-diameter and glycerin-cryopreserved grafts for eccentric corneal perforation. Methods: In this retrospective consecutive case series, 15 eyes of 15 patients with eccentric corneal perforations underwent small-diameter penetrating keratoplasties with glycerin-cryopreserved grafts. The corneal grafts used in this study were 2.5-4.5 mm in size and preserved at −20°C in pure glycerin for 6 months to 5 years. The donors were secured with 6-8 sutures that spared the visual axis. The follow-up ranged from 7 to 36 months. Clarity of the grafts was observed, and changes in visual acuity and keratometric astigmatism were analyzed. Results: Global integrity was achieved in all eyes. All grafts remained clear at the end of the follow-up time. No immune rejection was detected. No complicated cataract or secondary glaucoma was developed. The uncorrected visual acuity improved from preoperative 20/2000 ~ 20/60 to postoperative 20/40 ~ 20/20, and the best-corrected visual acuity after surgery was 20/30 or better. The mean value of keratometric astigmatism was 2.47 ± 0.78 diopters postoperatively. Conclusions: Small-diameter penetrating keratoplasty seems to be effective in treating various eccentric corneal perforations. Glycerin-cryopreserved donors may be a suitable alternative to fresh material for this technique, which solves the problem of shortage in supplying corneas and can be used in an emergency.

Indications of paediatric keratoplasty in north China

Purpose:  To analyse indications of paediatric keratoplasty in north China and provide information for the prevention of corneal blindness.

An essential role for dendritic cells in vernal keratoconjunctivitis: analysis by laser scanning confocal microscopy.

CD4+ T helper type 2 cells play a central role in the pathogenesis of vernal keratoconjunctivitis (VKC), and antigen‐presenting cells are required for the cell activation. In this study, we aimed to survey the density, distribution, and morphology of dendritic cells (DCs) in patients with VKC by in vivo confocal microscopy.

Modified Deep Lamellar Keratoplasty for the Treatment of Advanced-Stage Keratoconus with Steep Curvature

PURPOSE To determine the clinical efficacy of modified deep lamellar keratoplasty for the treatment of advanced-stage keratoconus with steep curvature. DESIGN Retrospective, noncomparative clinical trial. PARTICIPANTS Fifty-nine keratoconus patients with a curvature of more than 60 diopters (D) in 65 eyes were studied. All affected eyes were in the advanced stage with typical clinical characteristics, and 31 of the eyes had midstromal scars in the central cornea. METHODS All patients were treated with modified deep lamellar keratoplasty. Briefly, four-fifths thickness of the corneal lamellae was cut using a Hessburg-Barron vacuum trephine (with a diameter of 7.75 mm). The incisal edge of the cornea was drawn using toothed forceps, and the lamellae were cut with a diamond knife along the stromal fibers. At the top of the cone, 2 mm (in diameter) of Descemets membrane was left. A corneal graft (8.0 mm in diameter) was sutured to the recipient using a gradual pressure technique to decrease the occurrence of folds in the central cornea. Complications during and after the surgery were recorded. The transparency of the graft, eye vision, and cornea curvature were monitored during follow-ups. MAIN OUTCOME MEASURES Surgical effect and visual acuity after modified deep lamellar keratoplasty in patients with keratoconus. RESULTS No corneal perforation occurred during the operations. Nine patients had mild liquid accumulation underneath the graft, but it disappeared 1 to 2 days after the surgery. The corneal graft attached to the patients eye well, and there was no obvious fold in the center. The average best-corrected visual acuity was 20/32 between 3 months and 1 year after surgery and reached 20/25 at 1 year after the operation. There was no detectable corneal graft rejection during the follow-ups. CONCLUSIONS This modified deep lamellar keratoplasty procedure for the treatment of keratoconus in patients with advanced-stage disease and steep curvature seems to provide similar efficacy to penetrating keratoplasty and may decrease the risk of immune rejection when compared with historical outcomes.

Clinical observation of removal of the necrotic corneal tissue combined with conjunctival flap covering surgery under the guidance of the AS-OCT in treatment of fungal keratitis

AIM To study the clinical observation of removal of the necrotic corneal tissue combined with conjunctival flap covering surgery under the guidance of the AS-OCT in treatment of fungal keratitis. METHODS A retrospective study was done to 10 patients (10 eyes) who had accepted removal of the necrotic corneal tissue combined with conjunctival flap covering surgery for fungal keratitis,the diagnosis by corneal scraping and smear examination or confocal microscopy check hyphae.Local and systemic antifungal therapy more than one week for all patients, corneal ulcer enlarge or no shrink.Slit lamp microscope examination the diameter of corneal ulcer about 2mm-4mm.Anterior segment optical coherence tomography (AS-OCT) examine the depth of corneal ulcer between 1/3-1/2,infiltrate corneal stroma about 20um-80um,the diameter of corneal ulcer about 3mm-6mm.Type-B ultrasonic exclusion endophthalmitis. Complete removal lesions until transparent of stroma, make conjunctival flap equal or greater than ulcer 1mm nearby conjunctiva. Continued antifungal therapy. The vision, fungal recurrence, conjunctival flap rollback or desquamate were analysed. RESULTS Ten patients had success done this surgery, the corneal ulcer was not enlarge and healing afteroperation.7 cases were bridging conjunctival flap and 3cases were single conjunctival flap. Preoperation vision above 0.1 had 8 cases,7 cases had vision above 0.1 one week after surgery, while 1 cases vision droped from 0.3 to 0.05.There was not recurrent for fungal,2 cases conjunctival flap rollback:1 case was bridging and 1case was single flap, no conjunctival flap desquamate. CONCLUSION It is safe and effective to perform removal of the necrotic corneal tissue combined with conjunctival flap covering surgery under the guidance of the AS-OCT in treatment of fungal keratitis which werenot sensitive or aggravate for antifungal drugs.

Big Bubble Deep Anterior Lamellar Keratoplasty for Management of Deep Fungal Keratitis

Objective. To evaluate the therapeutic effect of big bubble deep anterior lamellar keratoplasty (DALK) in patients with deep fungal keratitis. Methods.Consecutive patients who had DALK for deep fungal keratitis at Shandong Eye Hospital between July 2011 and December 2012 were included. In all patients, the infiltration depth was more than 4/5ths of the corneal thickness. DALK surgery was performed with bare Descemet membrane (DM) using the big bubble technique. Corrected distance visual acuity (CDVA), graft status, and intraoperative and postoperative complications were monitored. Results. Big bubble DALK was performed in 23 patients (23 eyes). Intraoperative perforation of the DM occurred in two eyes (8.7%) during stromal dissection. The patients received lamellar keratoplasty with an air bubble injected into the anterior chamber. Double anterior chamber formed in 3 eyes (13.0%). Mean CDVA of the patients without cataract, amblyopia, and fungal recurrence was improved from preoperative HM/20 cm−1.0 (LogMAR) to 0.23 ± 0.13 (LogMAR) at the last followup (P < 0.01). Fungal recurrence was found in two patients (8.7%). Corneal stromal graft rejection was noted in one patient (4.3%). Conclusions. DALK using the big bubble technique seems to be effective and safe in the treatment of deep fungal keratitis unresponsive to medication.

Modified lamellar keratoplasty and immunosuppressive therapy guided by in vivo confocal microscopy for perforated Mooren's ulcer

Aim To observe the efficacy of modified lamellar keratoplasty (LK) and immunosuppressive therapy guided by in vivo confocal microscopy (IVCM) for perforated Moorens ulcer. Methods 25 patients (31 eyes) with perforated Moorens ulcer underwent modified LK. The perforated hole was patched with a thin, fresh posterior cornea containing the endothelium, before a glycerin-preserved lamellar graft shaped like the defect was placed. Immunosuppressants and corticosteroids were used and their dosages adjusted following the density of dendritic cells in the corneal graft postoperatively as detected by IVCM. The anatomical recovery, visual acuity, surgical complications, and recurrence were followed up for 24 months. Results Favourable anatomical recovery was achieved in 27 eyes (87.1%). The vision was significantly improved in all eyes (p<0.05). Four eyes (12.9%) had leakage at the graft–host interface. No allograft autolysis or immunological rejection was observed. A large number of dendritic cells existed in the peripheral and central graft at 1 week postoperatively, with a mean density of 359.47±97.21 cells/mm2 and 216.93±57.86 cells/mm2, respectively, which significantly decreased to 93.83±31.07 cells/mm2 and 43.65±28.43 cells/mm2 at 2 months. Accordingly, the dosage of medication was gradually reduced during this period. At 6 months, if no dendritic cells were found in the graft, use of the topical drug was stopped. The disease recurrence rate was 9.7%. Conclusions Modified LK, combined with immunosuppressive therapy, can effectively treat perforated Moorens ulcer, with few complications. The use of corticosteroids and immunosuppressants guided by IVCM may reduce the disease recurrence.

Combined anterior chamber washout, amniotic membrane transplantation, and topical use of corticosteroids for severe peripheral ulcerative keratitis.

Purpose: The aim of this study was to evaluate the efficacy of anterior chamber washout, amniotic membrane transplantation, and topical use of corticosteroids in the treatment of severe peripheral ulcerative keratitis with membranous endothelial exudation. Methods: Twelve patients (12 eyes) with severe corneal ulceration were included. All ulcers were located at the corneal periphery, accompanied by central corneal epithelial defects and stromal edema. Membranous endothelial exudates were observed by anterior segment optical coherence tomography. The duration of the ulcers was 1 to 10 months (mean, 3.0 ± 2.9 months) before the patients visited our institution. Corneal inflammation and ulceration could not be controlled after 2 weeks of topical antiinflammation treatment. Bacterial, fungal, and Acanthamoeba infections were not detected. Surgical treatment was performed. After the necrotic corneal tissue was cut, exudation clinging to the endothelium was removed. Then, amniotic membrane was placed on the corneal lesion. Postoperatively, corticosteroid eye drops and topical and systemic antiinflammation medication were given. Healing of corneal ulcers and improvement of stromal edema were detected by slit-lamp microscopy. All patients were followed up for 3 to 15 months (mean, 6.5 ± 3.7 months). Results: All corneal ulcers healed by 1 to 2 weeks after surgery. The corneal stromal edema subsided within 1 month. All patients achieved a stable ocular surface. There was no recurrence during the follow-up. Conclusions: Anterior chamber washout and amniotic membrane transplantation combined with topical corticosteroids seems to be effective for the treatment of severe peripheral ulcerative keratitis with endothelial exudates.

Decreased Integrity, Content, and Increased Transcript Level of Mitochondrial DNA Are Associated with Keratoconus.

Oxidative stress may play an important role in the pathogenesis of keratoconus (KC). Mitochondrial DNA (mtDNA) is involved in mitochondrial function, and the mtDNA content, integrity, and transcript level may affect the generation of reactive oxygen species (ROS) and be involved in the pathogenesis of KC. We designed a case-control study to research the relationship between KC and mtDNA integrity, content and transcription. One-hundred ninety-eight KC corneas and 106 normal corneas from Chinese patients were studied. Quantitative real-time PCR was used to measure the relative mtDNA content, transcript levels of mtDNA and related genes. Long-extension PCR was used to detect mtDNA damage. ROS, mitochondrial membrane potential and ATP were measured by respective assay kit, and Mito-Tracker Green was used to label the mitochondria. The relative mtDNA content of KC corneas was significantly lower than that of normal corneas (P = 9.19×10−24), possibly due to decreased expression of the mitochondrial transcription factor A (TFAM) gene (P = 3.26×10−3). In contrast, the transcript levels of mtDNA genes were significantly increased in KC corneas compared with normal corneas (NADH dehydrogenase subunit 1 [ND1]: P = 1.79×10−3; cytochrome c oxidase subunit 1 [COX1]: P = 1.54×10−3; NADH dehydrogenase subunit 1, [ND6]: P = 4.62×10−3). The latter may be the result of increased expression levels of mtDNA transcription-related genes mitochondrial RNA polymerase (POLRMT) (P = 2.55×10−4) and transcription factor B2 mitochondrial (TFB2M) (P = 7.88×10−5). KC corneas also had increased mtDNA damage (P = 3.63×10−10), higher ROS levels, and lower mitochondrial membrane potential and ATP levels compared with normal corneas. Decreased integrity, content and increased transcript level of mtDNA are associated with KC. These changes may affect the generation of ROS and play a role in the pathogenesis of KC.