Toine Hillenaar

Endothelial involvement in herpes simplex virus keratitis: an in vivo confocal microscopy study.

PURPOSE To describe the appearance, frequency, and clinical consequences of corneal endothelial involvement in human herpes simplex virus (HSV) keratitis as seen by in vivo confocal microscopy (IVCM). DESIGN Prospective observational case series. PARTICIPANTS A total of 285 patients with HSV keratitis who visited the cornea department of the Rotterdam Eye Hospital between May 2005 and May 2008. The control groups comprised the unaffected fellow eyes of patients with HSV keratitis, the eyes of 58 healthy volunteers, and the affected eyes of 62 patients with inflammatory corneal disorders other than HSV. METHODS We examined the eyes of all participants by IVCM and slit-lamp examination. For IVCM, corneas were scanned with Confoscan 3 or 4 (Nidek Technologies, Albignasego, Padova, Italy). MAIN OUTCOME MEASURES All IVCM examinations were qualitatively reviewed for signs of endothelial deviations characteristic of endotheliitis. Endothelial cell density (ECD) was evaluated on the first and last visits of patients who were followed for more than 100 days. The differences in ECDs were calculated and converted to percent ECD change per year. RESULTS Endothelial alterations characteristic of endotheliitis were detected by IVCM in 107 of 250 patients with HSV keratitis (43%). These deviations consisted of pseudoguttata, enlarged intercellular gaps, infiltration of inflammatory cells into the endothelial layer, loss of defined cell boundaries, spot-like holes, and endothelial denudation. All of these signs disappeared with appropriate antiviral and anti-inflammatory treatment. However, the endothelium in eyes with endotheliitis-characteristic alterations showed a significant decrease in ECD (10.3% per year) compared with healthy fellow eyes. CONCLUSIONS IVCM allows earlier detection of endothelial alterations in patients with HSV keratitis compared with slit-lamp examination. Although endotheliitis-specific alterations appear to resolve, the corneal endothelium can become irreversibly damaged.

Normative database for corneal backscatter analysis by in vivo confocal microscopy

PURPOSE To ascertain the sex and age relatedness, diurnal variation, and repeatability of backscatter measurement in the normal human cornea. METHODS Seven corneal backscatter variants were measured by in vivo confocal microscopy (IVCM) in both normal eyes (n = 314) of 157 healthy subjects. These subjects were assigned to one or more of three groups. The sex and age relatedness of corneal backscatter were assessed in group 1 (n = 300), which comprised 75 men and 75 women evenly distributed over five age categories. To assess diurnal variation, eyes in group 2 (n = 40) were measured four times a day, at 3-hour intervals. The eyes in group 3 (n = 50) were examined four times a year to determine intersession repeatability. Intrasession repeatability was determined by performing all IVCM examinations in duplicate. Linear mixed models were used to assess the effects of sex, age, and time of measurement on corneal backscatter. RESULTS Mean corneal backscatter was 3.5% higher in men (P = 0.003). From the age of 50 years, backscatter increased significantly in the anterior stroma (P = 0.0003). A small but statistically significant diurnal variation was found in all seven backscatter variants (P < 0.01). The test-retest coefficient of variation of mean corneal backscatter was 5.3%, comprising intra- and intersession repeatability. CONCLUSIONS Sex and time of measurement significantly affect corneal backscatter measured by IVCM, whereas age affects only backscatter in the anterior stroma. All three factors should be taken into account when conducting scientific research. For ophthalmic practice, the authors suggest ignoring these factors and propose a generalized normal range and minimum detectable change for each backscatter variant.

Graft insertion during Descemet-stripping automated endothelial keratoplasty: Pulling the graft inward

&NA; We describe a technique to facilitate insertion of the folded donor graft during Descemet‐stripping automated endothelial keratoplasty (DSAEK). Surgery is performed using a standard technique, and the graft is pulled into the anterior chamber using a double‐armed 10‐0 polypropylene suture with straight 16 mm needles. The technique of pulling the graft inside the anterior chamber is easy and ensures that the graft is inserted and unfolded in the right direction. There is no compression of tissue so mechanical trauma to the endothelium is less than when an inserting forceps is used. The results in 12 cases are presented.

Long-term follow-up of hydrogel intracorneal lenses in 2 aphakic eyes

We report the outcome of hydrogel intracorneal lens implantation in 2 patients. The lenses were implanted at approximately 50% depth in the cornea to correct high hyperopic refractive errors of 10.5 diopters (D) and 14.0 D, respectively. Both patients were contact lens intolerant and not suitable for intraocular lens implantation. Surgery was performed in 1988, and the patients were followed until early 2010. The patients showed good tolerance for the intracorneal lenses, but both developed opacities around the implant, leading to reduced visual acuity in 1 patient. Long-term patient monitoring is essential since corneal opacities can develop after many years. Removing the implant is not necessary as the lens can easily be rinsed by lifting the corneal cap.