Uri Elbaz

Restoration of Corneal Sensation With Regional Nerve Transfers and Nerve Grafts: A New Approach to a Difficult Problem

IMPORTANCEnCorneal anesthesia is recalcitrant to conventional treatment and can lead to permanent visual loss.nnnOBJECTIVEnTo assess the outcomes of a novel sensory reconstructive technique for the treatment of corneal anesthesia.nnnDESIGN, SETTING, AND PARTICIPANTSnThis prospective study evaluating a new technique was conducted at a tertiary referral center. Four eyes in 3 patients with corneal anesthesia underwent nerve transfers with nerve grafting to restore corneal sensation. Corneal sensory reconstruction was performed using a segment of the medial cutaneous branch of the sural nerve. Two patients with unilateral trigeminal nerve anesthesia-one following basal skull fracture and another following large posterior fossa tumor resection-underwent corneal sensory reconstruction using the contralateral supratrochlear nerve as the donor sensory nerve. One patient with a history of cerebellar hypoplasia and bilateral congenital corneal anesthesia underwent bilateral corneal sensory reconstruction using the respective ipsilateral supratrochlear nerves as the sensory donor nerves. Corneal anesthesia was evaluated preoperatively and postoperatively in the center of the cornea and in 4 corneal quadrants using a Cochet-Bonnet esthesiometer (Luneau). Complications of the procedure were also documented.nnnMAIN OUTCOMES AND MEASURESnEsthesiometry scores.nnnRESULTSnAll eyes had prior complications of corneal anesthesia and had no measurable corneal sensation in the affected eye(s) preoperatively. Two patients-one with cerebellar hypoplasia and the other with posterior fossa tumor resection-had markedly improved corneal sensation 6 months postsurgery (3 eyes; mean [SD] central esthesiometry, 55 [5] mm). A third patient with a history of basal skull fracture underwent unilateral corneal neurotization and recovered 15-mm esthesiometry score centrally after 7.5 months of follow-up. None of the operated on eyes have developed corneal anesthesia-related complications since reconstruction.nnnCONCLUSIONS AND RELEVANCEnCorneal sensory reconstruction provides corneal sensation in previously anesthetic corneas. This can be achieved with minimal morbidity using sural nerve grafts, which surgeons commonly use to reconstruct nerve gaps elsewhere. This multidisciplinary approach restores an ocular defense mechanism and may enable subsequent corneal transplant in these patients.

Anterior Stromal Puncture for the Treatment of Recurrent Corneal Erosion Syndrome: Patient Clinical Features and Outcomes

PURPOSEnTo evaluate the clinical features and outcomes of patients with recurrent corneal erosion syndrome who underwent anterior stromal puncture.nnnSTUDY DESIGNnRetrospective, nonrandomized, consecutive case series.nnnMETHODSnDatabase search of patients from 2003-2013 who underwent anterior stromal puncture was conducted at a tertiary care hospital cornea clinic. Charts of 30 patients (35 eyes) were reviewed. Outcome measures included demographics, laterality, history of corneal trauma, prior ocular history, frequency and duration of symptoms, failed treatments, signs on examination, degree of symptom resolution, additional treatments needed, and complications.nnnRESULTSnMean patient age at presentation was 37 (± 11.5 SD) years, 60% were male. A total of 83.3% of patients had unilateral and 16.7% had bilateral involvement. In all, 62.9% of eyes had prior history of corneal trauma and 2.9% had prior laser-assisted in situ keratomileusis. Ninety-seven percent of eyes had symptoms of pain upon awakening refractory to conservative treatment. In 97% of eyes, there were findings of microcysts, fingerprint lines, loose epithelium, and/or faint scars. Mean follow-up was 14 months (range: 3-120 months). At final follow-up, 62.9% of eyes were symptom free and 37.1% experienced milder episodes. Seventeen percent required additional treatment: 16.6% superficial keratectomy, 66% repeat anterior stromal puncture, and 16.7% phototherapeutic keratectomy. No complications were observed.nnnCONCLUSIONnAnterior stromal puncture using a short (5/8 inch) 25 gauge bent needle is a simple, safe, and cost-effective procedure for symptomatic relief in patients with recurrent corneal erosion syndrome refractive to conservative measures. Repeat treatment may be performed prior to additional surgical intervention.

Corneal Endothelial Cell Density in Children: Normative Data From Birth to 5 Years Old

PURPOSEnTo establish a normative database of endothelial cell density (ECD) using inxa0vivo specular microscopy in children under 5 years old.nnnDESIGNnCross-sectional study.nnnMETHODSnSpecular microscopy was performed during a clinic visit in cooperative children in the standard upright position. In uncooperative children, specular microscopy was performed in the lateral decubitus position under general anesthesia, before surgery for other reasons. Corneal diameter (CD) was measured in children undergoing general anesthesia and was stratified according to age.nnnRESULTSnOne hundred and eighteen eyes of 118 patients were included in the study. The mean patient age was 2.6 ± 1.4 years (range 0.1-5 years) and the mean ECD was 3746 ± 370 cells/mm2 (range 3145-5013 cells/mm2). The mean CD under 2 years of age was 11.85 ± 0.57xa0mm (nxa0= 40, range 10.50-12.75xa0mm). Up to 2 years of age, ECD was more inversely correlated with CD than with age (rxa0=xa0-0.61, P < .0001; rxa0=xa0-0.38, Pxa0= .01, respectively). In contrast, after the age of 2 years, the ECD was inversely correlated with age but not with CD (rxa0=xa0-0.27, Pxa0= .02; rxa0=xa0-0.24, Pxa0= .2). Between the first and second year of life, the rate of ECD decrease was significantly higher than between 2 and 5 years of age (8.2%, 334 cells/mm2 vs 2.7%, 100 cells/mm2 a year, respectively).nnnCONCLUSIONnIn the first 2 years of life there is a rapid decline in ECD, which is likely related to growth in CD and hence surface area. After the cornea reaches adult size, the ECD decreases at a rate similar to that reported in adults.

Validation of Corneal Endothelial Specular Microscopy in Children Under General Anesthesia

Validation of Corneal Endothelial Specular Microscopy in Children Under General Anesthesia Our current knowledge of the corneal endothelium in early childhood including its development and response to disease and surgery is suboptimal,1-3 largely owing to the technical difficulties involved in obtaining specular microscopy (SM) images in very young patients. The gold-standard technique for SM is to acquire images with central fixation while the patient is alert and upright, enabling images of the same corneal region each time. We have modified this technique to capture SM images in children under general anesthesia (GA) who are positioned in the lateral decubitus position with centration of the eye in the display reticle. However, because the patient is not able to fixate on a target, it is not clear whether this acquisition technique is reproducible.

Avoiding big bubble complications: outcomes of layer-by-layer deep anterior lamellar keratoplasty in children

Background/aims To describe the visual and clinical outcomes of manual layer-by-layer deep anterior lamellar keratoplasty (DALK) in a paediatric population. Methods The charts of all children who underwent DALK surgery between January 2007 and January 2015 were reviewed retrospectively. Data collected included preoperative and postoperative spectacle-corrected distance visual acuity (CDVA), intraoperative and postoperative complications including graft rejection and failure. Residual posterior lamellar thickness (RPLT) and endothelial cell density (ECD) were measured in eyes with follow-up longer than 6 months. Results Fifty-one eyes of 42 patients were included in the study. The mean patient age at surgery was 11.2±5.2 years and the mean follow-up time was 36.5±23.7 months. The most common indications for surgery were mucopolysaccharidosis (29.4%) and keratoconus (23.5%). Nine eyes (17.6%) had intraoperative microperforation, none of which were converted to penetrating keratoplasty (PKP). Only one eye (2.0%) was converted to PKP. Five eyes (9.8%) had a stromal rejection episode of which one eye failed. Another four eyes (7.8%) experienced graft failure among which three eyes (75%) had infectious keratitis. Three of the five failed grafts had a successful repeat DALK. The average RPLT was 81.9±36.5μm. ECD was significantly lower in the operated eye compared with the normal eye (3096±333 cells/mm2 vs 3376±342 cells/mm2, n=11, P=0.003). The mean postoperative CDVA was 0.5±0.4u2009logarithm of the minimum angle of resolution (logMAR) reflecting a gain of 0.3 logMAR (P<0.001). Conclusion Manual dissection DALK is a safe procedure in children with stromal opacities. Despite successful structural rehabilitation, functional recovery is still suboptimal mostly due to amblyopia.