Clinical observation of deep lamellar keratoplasty for herpes simplex viral keratitis / 国际眼科杂志(Guoji Yanke Zazhi)

AIM: To investigate the clinical effects on the deep lamellar keratoplasty for herpes simplex keratitis. METHODS: Deep lamellar keratoplasty was performed on 105 cases with herpes simplex viral keratitis. All of these patients were followed-up for 12-36mo, the corneal graft transparency, visual acuity and viral keratitis recurrence were observed. RESULTS:Among 24 patients after stripping the corneal stroma which was close to the Descemet's membrane, Central area of 81 cases were about 6mmí6mm of to Descemet's membrane. One hundred and one cases of planting beds were transparent. Visual acuity were improved in varying degrees, best corrected visual acuity was greater than 0. 5 in 67 cases, 0. 3-0. 5 in 35 cases, less than 0. 3 in 3 cases. There was no recurrence of viral keratitis and rejection cases during the observation period. CONCLUSION: Deep lamellar keratoplasty is an effective technique in the treatment of viral keratitis. It is therefore should be an early surgical treatment for frequent episodes of viral keratitis cases.

Ultrastructure and histopathology of cornea after femtosecond laser-assisted deep lamellar keratoplasty for acute corneal alkali burn / 中华实验眼科杂志

Background To maintain corneal transparency is important for good visual function.A new treatment concept and the selection of surgical techniques and timing of surgery are critical for stopping the infringement of cornea tissue after alkali burning and other chemical warfare agents.Objective This study was to investigative the ultrastructure and histopathological status following the femtosecond laser-assisted deep lamellar keratoplasty (DLK) for acute alkali burn of cornea.Methods Acute corneal alkali burn models were established in 12 New Zealand rabbits by putting the 6 mm filter paper with 1 mol/L NaOH at the central cornea for 30 seconds.The rabbits were randomly allocated to femtosecond laser-assisted DLK group and model control group according to the randomized number table method.Femtosecond laser-assisted DLK was performed to transplant the corneal grafts of domestic rabbits to the model rabbits 24 hours after burning.The rabbits were sacrificed 1 week,2 weeks and 4 weeks after modeling,and the corneas were extracted for the preparation of corneal section.The cornea were performed with hematoxylin and eosin staining to assess the histopathological status under the optical microscope,and the ultrastructure of grafts and corneas was examined under the transmission electron microscope (TEM).Results Acute corneal alkali bourn models were successfully eatablished.In the fourth week after surgery,corneal graft was clear in the femtosecond laser-assisted DLK group.However,corneal swelling,conjunctival congestion and neovascularization were found in the model control group.Histopathological examination revealed the defect of corneal epithelium,edema of stroma,loose arrangement of collagen fibers,much vacuoles,few neovascularization and infiltration of a large number of inflammatory cells in the model control group,but in the femtosecond laser-assisted DLK group,the inflammatory response was slight.More desmosomes among the endothelial cells were seen,and the nuclei were intact in the grafts.In the fourth week after surgery,the transplanted corneas were transparent with the regular arrangement of collagen fibers and entire fibroblasts in the femtosecond laser-assisted DLK group under the TEM.However,flat surface corneal epithelial cells and shedding of some epithelial cells were exhibited in the modelcontrol group.Conclusions Femtosecond laser-assisted DLK can effectively alleviate the inflammatory response,promote epithelial healing and enhance intercellular tight junction in the cornea with acute alkali burn.

Queratoplastia lamelar profunda asistida por tunelizador / Deep anterior lamellar keratoplasty assisted by prolate system

Objetivo: describir una nueva técnica quirúrgica para realizar queratoplastia lamelar profunda que facilita la disección de planos corneales a un espesor predeterminado, utilizando instrumental con el cual el cirujano de córnea está familiarizado. Métodos: se describe el caso de una paciente de 32 años con queratocono avanzado sin antecedente de hidrops, cicatrices estromales de la córnea o cirugía previa. Se realizó queratoplastia lamelar profunda en el ojo izquierdo inicialmente y tres meses después en el ojo derecho efectuando el procedimiento a profundidad conocida utilizando instrumental para implante de segmentos intraestromales Intacs® (Addition Technology, Inc., Fremont, CA). Se determinó un plano corneal con el disector de Melles (DORC®, Spijkenisse, Países Bajos) con posterior inyección de viscoelástico para su separación y realización del corte con trépanos de Barron (Katena products, inc. Denville, USA) para donante y receptor de un mismo diámetro (8mm) con sutura combinada con nylon 10-0 (Ethicon, Inc, San Angelo, USA). Resultados: se realizó seguimiento a 4 años con una AVSC de 20/150+1 OD y 20/80-1 OI. La mejor visión corregida lejana fué de 20/25 en OD y 20/20- en el OI. Conclusiones: la queratoplastia lamelar profunda asistida por tunelizador corneal promete ser una técnica segura que permite efectuar la disección a una profundidad planeada sin penetrar a cámara anterior. Se observaron excelentes resultados con una técnica amigable para el cirujano de córnea sin incrementar significativamente el tiempo quirúrgico y además, permitiendo obtener las ventajas al preservar el endotelio corneal con una técnica con cámara cerrada.

Purpose: to describe a new surgical technique for deep lamellar keratoplasty which facilitates corneal lamellar dissection to a predetermined thickness using instruments known by a corneal surgeon to implant Intacs intrastromal ring segments. Methods: We described a case of a 32 year old patient without history of hydrops, corneal stromal scars or previous corneal surgery. Deep lamellar keratoplasty was performed initially in the left eye and three months later in the right eye performing procedure in a known depth using Intacs® Prolate System (Addition Technology, Inc. Fremont, CA). Lamellar corneal dissection was performed with Melles dissector (DORC®, Spijkenisse Netherlands) and viscoelastic substance was injected to dissect planes. Trephination was performed with Barron-Hessburg corneal system (Katena products, inc. Denville, USA) with same size for donor and recipient (8mm) and sutured with a combined 10-0 Nylon suture technique (Ethicon, Inc, San Angelo, USA). Outcome: 4-years follow-up has show an UCVA of 20/150(+1) OD and 20/80(-1) OS. Best corrected distance vision of 20/25 OD and 20/208(-1) in OS were achieved. Conclusions: prolate system corneal assisted deep anterior lamellar keratoplasty promises to be a safe and novel technique allowing corneal dissection to a planned depth without anterior chamber penetration. Excellent results in a friendly technique to any corneal surgeon offers standard surgical time and the advantage to preserve recipient endothelium layer in a closed anterior chamber surgical technique.

Meta analysis of deep lamellar keratoplasty and penetrating keratoplasty for keratoconus / 中华实验眼科杂志

Background Nowadays,keratoplasty is widely used in the treatment of keratoconus.Deep lamellar keratoplasty(DLKP)is one of the research hotspots.However,its effacacy and safety are still concerned.Objective This paper was to evaluate and compare the therapeutic outcomes between DLKP and penetrating keratoplasty(PKP) for keratoconus.Methods The peer-reviewed and published literature was searched from PubMed database,Cochrane Library,EMBase and CNKI to identify relevant trails comparing DLKP with PKP for keratoconus.Methodological quality and Meta-analysis were carried out according to the principle of evidence-based medicine.The statistical analysis was performed using Review Manager 5.0 software.Results Eleven studies with 2950 eyes were identified that compared the results of DLKP and PKP procedures for keratoconus directly.Of those studies reporting vision and refractive data,less patients underwent DLKP achieved a best corrected visual acuity (BCVA)of≥0.5 than DLKP(RR=0.91,95％ CI:0.84-0.99,P=0.030) ;patients with DALK had severer myopia that those with PKP(RR =-0.60,95％ CI:-1.43-0.23,P =0.150),but the astigmatism was comparative (WMD =0.21,95％ CI:-0.48-0.91,P =0.550).Endothelial cell density values were higher in the DLKP group and the differences were significant.Endothelial immune graft rejection did not occur after DALK,and PKP had a higher overall graft rejection rate than DLKP(RR=0.06,95％ CI:0.01-0.31,P=0.001).Conclusions According to the available data,PKP can imporve the BCVA and refractive results,but DLKP can avoid the risk of endothelial rejection and reduce the risk of late endothelial failure for keratconus.

A Comparison of Posterior Lamellar Keratoplasty Modalities: DLEK vs. DSEK

PURPOSE: To compare clinical outcomes after deep lamellar endothelial keratoplasty (DLEK) with Descemet stripping endothelial keratoplasty (DSEK) performed as initial cases by a single surgeon. METHODS: Sixteen patients with corneal endothelial were enrolled. Eight patients (8 eyes) underwent DLEK and 8 patients (8 eyes) DSEK. We measured uncorrected visual acuity, best corrected visual acuity (BCVA), manifest refraction, corneal endothelial count, interface opacity via Schiempflug imaging, and contrast sensitivity, as well as tracked postoperative complications over the first postoperative year. RESULTS: Primary graft failure occurred in two DLEK cases and one DSEK case, all of which were excluded for further analysis. The average 12-month postoperative BCVA was 20/70 in the DLEK group and 20/50 in the DSEK group, with the difference not statistically significant. No significant differences were identified between the 2 groups in terms of mean spherical equivalent and refractive astigmatism, although individuals in the DSEK group tended toward hyperopia. The average endothelial cell count at postoperative month 12 was 1849+/-494 in the DLEK group and 1643+/-417 cells/mm2 in the DSEK group, representing cell losses of 26.2% and 31.9%, respectively. No significant differences in endothelial cell count or endothelial cell loss were observed between groups. Early postoperative donor disc dislocation occurred in two eyes after DLEK and one eye after DSEK. Interface opacities and contrast sensitivities were similarly not significantly different between groups. CONCLUSIONS: No significant differences in any assessed clinical outcome were observed between individuals undergoing DLEK and DSEK, when performed as initial cases by a single surgeon.

Three Cases of Urrets-Zavalia Syndrome Following Deep Lamellar Keratoplasty (DLKP)

PURPOSE: To report three cases of Urrets-Zavalia syndrome after deep lamellar keratoplasty. CASE SUMMARY: A retrospective chart analysis of two men who underwent deep lamellar keraplasty after corneal chemical burns and one woman who was treated with deep lamellar keratoplasty due to lattice dystrophy was performed. To maintain the anterior chamber depth and prevent formation of a double anterior chamber after deep lamellar keratoplasty, air or gas (C3F8) was injected into the anterior chamber for all three cases. After injections of air or gas (C3F8) into the anterior chamber, pupillary blocks occurred and intraocular pressures increased. Afterwards, intraocular pressures were well-controlled, but the pupil remained irreversibly fixed and dilated despite the use of miotics. CONCLUSIONS: Urrets-Zavalia syndrome, a postoperative complication, was first reported in a patient who underwent penetrating keratoplasty for keratoconus. This syndrome can also occur after deep lamellar keratoplasty on rare occasions.

The Number of Cases, Cause and Treatment of Avellino Corneal Dystrophy Exacerbated After LASIK

PURPOSE: To present a case report of fungal keratitis related to prolonged overnight use of orthokeratology contact lenses. METHODS: A 13 year-old girl presented with a corneal ulcer in her left eye refractory to antibacterial medication. She had a history of wearing orthokeratology contact lenses overnight for seven months. RESULTS: The organism Aspergillus was isolated by corneal scraping, the contact lens itself, and from the storage case. The patient was treated with topical fluconazole and Natamycin pimaricin in addition to oral itraconazole, resulting in a resolution of the ocular lesion. CONCLUSIONS: The risk of fungal infection as a potential complication of the use of overnight orthkeratology contact lenses should be considered when using these lenses.

Effects of Intrastromal Air Injection Compared to Hydro-injection on Keratocyte Apoptosis

PURPOSE: To evaluate the effects of intrastromal air injection and intrastromal balanced salt solution (BSS) injection on corneal keratocyte apoptosis. METHODS: Twelve right eyes of New Zealand White rabbits were divided into an air-injected group (n=6) and a hydro-injected group (n=6). Contralateral eyes served as a control. Air or Balanced salt solution (BSS(R), Alcon, USA) was injected into the deep corneal stroma at the paracentral area to propagate into nearly the entire cornea. To reduce the intraocular pressure, anterior chamber paracentesis was performed. The animals were sacrificed 4 hours (n=6) and 24 hours (n=6) after surgery. Central cornea buttons were retrieved to stain with Hematoxylin & Eosin and TUNEL (Apoptag(R), Chemicon). The mean number of apoptotic keratocytes was counted in 24.67+/-4.04 consecutive high power field (HPF). RESULTS: The mean number of TUNEL-positive cells at 4 hours was 12.85+/-7.25/HPF and 0.25+/-0.44/HPF in air-injected and hydro-injected eyes, respectively. It was reduced to 6.25+/-4.02/HPF and 0.15+/-0.37/HPF in air-injected and hydro-injected eyes after 24 hours. The air-injected group showed significantly more TUNEL-positive cells compared with the hydro-injected or control group until 24 hours (p=0.001, p=0.001, Mann-Whitney U test). CONCLUSIONS: Intrastromal air injection induces significant apoptosis of keratocytes suggesting some damages in the peripheral cornea when used in deep lamellar keratoplasty.

Surgical Results of Deep Lamellar Keratoplasty

We performed the deep lamellar keratoplasties in which stroma about 90% in thickness were removed on 15 patients(12 males and 3 females). The patients included in this study showed deep corneal opacity preserving endothelium intact. During the operation, we experienced microperforation in 3 cases, but no complications were found with immediate closure. After the operation, all patients acquired the corneal clarity except one whose cornea was opaque as the Grade II by the slit lamp examination. The patients had visual improvement of two lines or more in Snellen chart. Three patients had no change of visual acuity and one patient bad astigmatism more than 3D. Only one patient suffered the stromal rejection raction, but improved with the use of oral steroid and topical steroid eye drops.

Deep lamellar keratoplasty:a new surgical technique for corneal clarity recovery / 眼科

As compared with penetrating keratoplasty(PKP), deep lamellar keratoplasty(DLKP) offers the same effect for recovery of corneal clarity in patients who have corneal stromal abnormality and/or opacity with normal endothelium. Many technical advances have been made for carrying out DLKP during past decade. However, the current status of the surgery is still technical difficulty, time consuming, possibly incomplete removal of recipient stroma or perforation of Descemet's membrane. As there may be further improvement of the technique, DLKP can be mastered by more ophthalmologists to treat patients who are currently considered as candidates for PKP. (Ophthalmol CHN, 2006, 15:156-158 )