Terrence P. O'Brien

Complications of Descemet's Stripping with Automated Endothelial Keratoplasty Survey of 118 Eyes at One Institute

PURPOSEnTo compile a survey of complications during and after Descemets stripping with automated endothelial keratoplasty (DSAEK) in 118 eyes conducted by cornea subspecialists at a single academic center.nnnDESIGNnRetrospective case series.nnnPARTICIPANTSnOne hundred eighteen eyes undergoing DSAEK in 99 patients.nnnMETHODSnOutcomes of DSAEK performed in 118 eyes by 10 surgeons were reviewed retrospectively. Sixty-four eyes had pseudophakic bullous keratopathy. Forty-one had Fuchs endothelial dystrophy and cataract. Three had aphakic bullous keratopathy. In 10 eyes, previous DSAEK performed at the same institution failed. Complications of DSAEK were noted from the intraoperative and postoperative periods. Detached DSAEK grafts were repositioned, rebubbled, or both immediately after diagnosis of this complication.nnnMAIN OUTCOME MEASURESnIntraoperative and postoperative complications of DSAEK.nnnRESULTSnGraft detachment was the most common type of complication encountered. In 27 (23%) of 118 eyes, graft detachments were observed. Twenty-five eyes with detached grafts successfully were repositioned or rebubbled after surgery, or both. In 1 eye, a previously detached graft reattached spontaneously. In 1 aphakic eye, the graft detached into the vitreous cavity. In 17 eyes, successful reattachment of the cornea occurred (68%). Twenty-one of the 118 eyes were considered to have failed DSAEK, meaning that persistent edema was present after DSAEK. Seven (6%) demonstrated graft rejection. In 5 eyes (4%), retinal detachment (RD) developed. In 6 (5%), cystoid macular edema developed. In 1 aphakic patient, an air bubble could not be maintained during surgery, and sulfur hexafluoride was injected into the anterior chamber. In 1 eye (1%), epithelial ingrowth developed. One eye (1%) demonstrated blood in the graft interface. In 1 eye (1%), a limited intraoperative suprachoroidal hemorrhage occurred. Two eyes (2%) had pupillary block after surgery that resolved with removal of the air bubble.nnnCONCLUSIONSnDescemets stripping with automated endothelial keratoplasty has become a popular and effective treatment for corneal endothelial dysfunction, but complications resulting from DSAEK do occur. Graft detachment is the most common complication, but postoperative repositioning or rebubbling, or both, allow for graft reattachment in most cases. Other complications found in this series were graft failure, graft rejection, cystoid macular edema, RD, suprachoroidal hemorrhage, and pupillary block. Retained Descemets membrane and epithelial ingrowth, are potential causes of dislocation.

The International Workshop on Meibomian Gland Dysfunction: Report of the Subcommittee on Management and Treatment of Meibomian Gland Dysfunction

The goals of the subcommittee were to review the current practice and published evidence of medical and surgical treatment options for meibomian gland dysfunction (MGD) and to identify areas with conflicting, or lack of, evidence, observations, concepts, or even mechanisms where further research is required. To achieve these goals, a comprehensive review of clinical textbooks and the scientific literature was performed and the quality of published evidence graded according to an agreed on standard, using objective criteria for clinical and basic research studies adapted from the American Academy of Ophthalmology Practice Guidelines1 (Table 1). It should be noted that, in many of the clinical textbooks and previous reports, terminology is often interchanged and the management of anterior and posterior blepharitis and/or meibomitis is often considered concurrently. Thus, a broad scope of documents was reviewed in this process. Consistency in terminology and global adoption of the term “meibomian gland dysfunction” would significantly aid clinical research and clinical care in MGD going forward. n n n nTable 1. n nGrading Level of Evidence of Clinical and Basic Research Studies1

Long-Term Results of Femtosecond Laser-Assisted Sutureless Anterior Lamellar Keratoplasty

PURPOSEnTo evaluate the long-term results of femtosecond laser-assisted anterior lamellar keratoplasty (FALK) for anterior corneal pathologies.nnnDESIGNnRetrospective, noncomparative, interventional case series.nnnPARTICIPANTSnThirteen consecutive patients who underwent FALK for anterior corneal pathologies.nnnINTERVENTIONnFemtosecond laser-assisted sutureless anterior lamellar keratoplasty.nnnMAIN OUTCOME MEASURESnBest spectacle-corrected visual acuity (BSCVA), manifest refraction, need for adjunctive surgery, and complications.nnnRESULTSnFollow-up ranged from 12 to 69 months (mean = 31 months). The BSCVA was significantly improved over preoperative values at the 12-, 18-, 24-, and 36-month visits. A BSCVA greater than 20/30 was achieved in 54% of patients at the 12-month visit when all 13 patients were available for follow-up, in 50% and 33% of patients at the 18- and 24-month visits, respectively, when 12 patients were available, and in 60% and 50% of patients at the 36- and 48-month visits when 5 and 2 patients were available, respectively. The BSCVA of the eye that completed the 60- and 70-month visits was 20/50. Patients achieved a mean gain of 5 lines of BSCVA at the 6-, 12-, 18-, and 24-month visits, 4 lines at the 36-month visit, 5 lines at the 48-month visit, and 6 lines at the 60- and 72-month visits. Two patients lost a mean of 1.5 lines of BSCVA because surface haze developed after photorefractive keratectomy (PRK) and granular dystrophy recurred in the graft. At a mean of 5 weeks postoperatively, 83.3% of patients achieved BSCVA within 2 lines of that recorded at the 24-month visit. At the 12-month visit, mean spherical equivalent and refractive astigmatism were -0.4 diopters (D) and 2.2 D, respectively, with no significant shift from preoperative values or values recorded in different follow-up visits. Adjunctive surgeries included phototherapeutic keratectomy, PRK, cataract extraction, and epithelial ingrowth debridement. Complications included residual corneal pathology, mild interface haze, anisometropia, recurrence of pathology, haze after adjunctive PRK, dry eye, epithelial ingrowth, and suspicious ectasia.nnnCONCLUSIONSnFemtosecond laser-assisted sutureless anterior lamellar keratoplasty improves the BSCVA of patients with anterior corneal pathologies with rapid visual rehabilitation and no significant induced astigmatism. Our preliminary results indicate that FALK results remained stable throughout the follow-up period.

Histopathologic Examination of Failed Grafts in Descemet's Stripping with Automated Endothelial Keratoplasty

PURPOSEnTo study the histopathologic features of 19 corneal posterior lamellar grafts in eyes for which Descemets stripping with automated endothelial keratoplasty (DSAEK) has failed.nnnDESIGNnRetrospective case series with clinicopathologic correlation.nnnPARTICIPANTSnNineteen cases of DSAEK failures undergoing repeat DSAEK or penetrating keratoplasty.nnnMETHODSnThe histopathologic results of posterior lamellar grafts (also termed DSAEK grafts), recipient corneas, or both from 19 cases of failed DSAEK were examined.nnnMAIN OUTCOME MEASURESnAbnormalities in the DSAEK graft and in the interface between the recipient cornea and the DSAEK graft were assessed.nnnRESULTSnHistopathologic features in 19 failed DSAEK grafts revealed attenuation of endothelial cells (16 cases) and presence in the graft-host interface of fibrocellular tissue (11 cases), retained Descemets membrane (5 cases), epithelial ingrowth (4 cases), or a combination thereof. Four DSAEK grafts had full-thickness corneal layers at 1 edge.nnnCONCLUSIONSnPresence of interface material, such as fibrocellular tissue, retained Descemets membrane, and epithelial ingrowth, are potential causes of dislocation. Endothelial attenuation was the most common finding in failed grafts. Decentered DSAEK grafts with full-thickness corneal layers at 1 edge are a potential cause for epithelial ingrowth.

Epithelial breakthrough during IntraLase flap creation for laser in situ keratomileusis

We report the clinical manifestations and outcomes in 4 patients who experienced premature gas-bubble leakage during raster lamellar dissection during IntraLase femtosecond laser corneal flap creation. Three patients experienced a full-thickness epithelial breakthrough and the fourth, a flap tear. The patient who experienced the flap tear was unable to have laser in situ keratomileusis successfully. The flap complications did not result in a decreased best corrected visual acuity in any patient but may have resulted in epithelial ingrowth in one and a corneal scar and microstriae in another. Potential predisposing factors for epithelial breakthrough, the incidence of epithelial breakthrough, and methods for avoiding and salvaging traumatic corneal flaps are discussed.

Second femtosecond laser pass for incomplete laser in situ keratomileusis flaps caused by suction loss

PURPOSE: To examine the technique of second‐pass femtosecond laser to correct an incomplete flap during laser in situ keratomileusis. SETTING: Department of Ophthalmology, Bascom Palmer Eye Institute, Miami, Florida, USA. METHODS: Twenty porcine eyes were assigned to 1 of 4 groups. In the first 2 groups, a flap was created with a femtosecond laser with a centrally black‐painted applanator at a 200 μm depth; a second flap was created at a 400 μm depth with the normal applanator. These groups differed by waiting or not waiting for the opaque bubble layer (OBL) to clear. In the third and fourth groups, the eyes were separated into those with and without OBL; however, the same depth was used for the second pass, which was performed after intentional suction loss. After these treatments, the corneas were examined using anterior segment optical coherence tomography (AS‐OCT) and the surgical microscope. RESULTS: In the first group (did not wait for OBL to clear), the peripheral shallow cut and the central deep line were observed in the AS‐OCT images, with corresponding findings under the surgical microscope. In the second group (waited for OBL to disappear), there were 2 parallel lines on the AS‐OCT images; the lines corresponded to dual flaps. In the third and fourth same‐depth‐cut tests, lines and irregularities were seen on the bed and the back of the flap. CONCLUSION: A second femtosecond laser pass for incomplete flaps, especially when the OBL has cleared, may result in an uneven lamellar cut.

Conjunctival Tissue Pharmacokinetic Properties of Topical Azithromycin 1% and Moxifloxacin 0.5% Ophthalmic Solutions: A Single-Dose, Randomized, Open-Label, Active-Controlled Trial in Healthy Adult Volunteers

BACKGROUNDnEffective ocular tissue concentrations and prolonged residence times of antibacterial agents are important in treating both acute and chronic diseases. Conjunctival biopsy allows the determination of specific tissue concentration data for topical ophthalmic agents. Drug concentration analysis at various time points following instillation allows interpretation of the residence time and a rationale for dosing frequency.nnnOBJECTIVEnThis study compared the pharmacokinetic parameters of 2 currently available topical ocular antibiotics-azithromycin ophthalmic solution 1% and moxifloxacin ophthalmic solution 0.5%-in the conjunctiva of healthy volunteers after a single topical administration.nnnMETHODSnThis single-dose, randomized, open-label, active-controlled clinical trial was conducted at ORA Clinical Research and Development, North Andover, Massachusetts. Subjects were randomly assigned to receive a single dose of azithromycin or moxifloxacin and to undergo biopsy sampling at 30 minutes or 2, 12, or 24 hours after administration. Concentrations of azithromycin and moxifloxacin were determined using liquid chromatography tandem mass spectrometry. Adverse events (AEs) were assessed at all visits using visual acuity measurements, slit-lamp biomicroscopy, and direct questioning.nnnRESULTSnForty-eight subjects (mean age, 40.0 years; 48% female; 96% white, 2% black, and 2% Asian) underwent conjunctival biopsy. Mean (SD) concentrations of azithromycin in conjunctival tissue (lower limit of quantitation [LLOQ], 1 microg/g for 1-mg biopsy specimen) were 131 (89), 59 (19), 48 (24), and 32 (20) microg/g at 30 minutes and 2, 12, and 24 hours, respectively (median values, 117, 69, 46, and 30 microg/g). Mean concentrations concentrations of moxifloxacin in conjunctival tissue (LLOQ, 0.05 microg/g for 1-mg biopsy sample) were 1.92 (2.03), 3.77 (8.98), 0.02 (0.04), and 0.01 (0.02) microg/g at 30 minutes and 2, 12, and 24 hours, respectively (median values, 1.12, 0.12, <0.05, and <0.05 microg/g). Thirteen subjects (6 in the azithromycin group and 7 in the moxifloxacin group) experienced 20 AEs, 11 of which were considered possibly related to study treatment, and 15 of which were ocular (most commonly conjunctival hemorrhage).nnnCONCLUSIONSnIn this single-dose study of 2 currently available topical ocular antibiotics in healthy volunteers, therapeutic concentrations were achieved with both agents. Both treatments were well tolerated in the population studied. Clinical Trials Identification Number: NCT00564447.

Effect of marking pens on femtosecond laser-assisted flap creation.

PURPOSE: To compare the ease of the flap lift after central corneal marking with 2 types of marking pens after femtosecond laser–assisted flap creation in laser in situ keratomileusis. SETTING: Bascom Palmer Eye Institute, University of Miami, Miami, Florida, USA. METHODS: Porcine eyes were prepared for flap creation with a femtosecond laser (IntraLase). The eyes were assigned to 1 of 4 groups. After the femtosecond laser treatment, the difficulty of flap lifting the 4 groups was compared. RESULTS: Twelve porcine eyes, 3 in each group, were evaluated. In the 2 groups in which an oil‐based pen was used, the corneal flap could not be lifted. In the 2 groups in which a water‐based pen was used, the corneal flap was easily lifted. CONCLUSIONS: Oil‐based ink may reduce the ability of the femtosecond laser to penetrate the cornea. The resultant corneal flap may require aggressive manipulation to be lifted. When used to mark the center of the cornea before flap creation, water‐based ink provided greater ease of corneal flap lifting than oil‐based ink. Because the marking is located over the center of the pupil, any alteration of the cornea in this area from aggressive flap lifting may result in substantial visual loss. Therefore, the use of an oil‐based ink to mark the central cornea must be avoided to prevent traumatic irregularities of the flap stroma.

Experimental model for analyzing cutting resistance by various knives for cataract surgery

Background:u2002 The trend in current cataract surgery towards clear corneal incision and sutureless procedures makes us realize the importance of wound construction. For optimal surgical outcomes, we need good surgical instruments. In this study, we employed a resistance recording system to analyze the characteristics of seven commercially available disposable cataract knives and to find clues for the future development of ‘good’ cataract knives.