In vivo confocal microstructural analysis of corneas presenting Kayser-Fleischer rings in patients with Wilson's disease / Análise microestrutural confocal in vivo de córneas apresentando anel de Kayser-Fleischer em pacientes com doença de Wilson

ABSTRACT Purpose: To evaluate microstructural differences between corneas with and without Kayser-Fleischer rings in age-matched subjects with Wilson's disease with neurological symptoms, using confocal laser scanning microscopy. Methods: The study included 12 subjects with Wilson's disease with neurological symptoms. Twelve corneas presented clinically with classic Kayser-Fleischer rings, visible on slit lamp examination; the other 12 served as controls. The subjects underwent a comprehensive clinical examination. Microstructural analysis using confocal laser scanning microscopy evaluated increased corneal thickness, decreased number of cells, increased debris or specific deposits, and unusual microstructures. Results: Clinically, the subjects with Kayser-Fleischer rings had similar corneal findings and normal intraocular pressure; two had typical sunflower cataracts and decreased visual acuity. The control eyes all presented normal visual acuity, intraocular pressure, and corneal appearance. The microstructural analysis demonstrated similar findings in all the affected corneas. Compared with the control corneas, there were fewer keratocytes in the anterior stroma (17.380 vs. 22.380/mm3). Round, "hollow" dark areas were observed between the keratocytes; these were universal and similar in appearance in all affected corneas and all cornea layers. In the peripheral posterior stroma, there were dust-like, bright, granular deposits that tended to increase in number and density toward Descemet's membrane, masking the peripheral endothelium. The control corneas presented a normal microstructure apart from dust-like granular deposits in the periphery. Conclusions: In vivo confocal microscopy is a useful tool for evaluating the corneal microstructure when a Kayser-Fleischer ring is clinically present. The ring consists of granular, bright particles that increase in density toward Descemet's membrane, and is associated with a decreased number of keratocytes and peculiar dark, round areas in all stromal layers, probably a sign of corneal damage. When the ring is not visible in subjects with Wilson's disease, changes to the corneal microstructure are insignificant.

RESUMO Objetivo: Avaliar, ao nível microestrutural, através de microscopia confocal in vivo a lazer, 12 córneas com anel de Kayser-Fleischer visível ao exame da lâmpada de fenda e compará-las com 12 córneas clinicamente normais de indivíduos com idades correspondentes aos pacientes com doença de Wilson e sintomas neurológicos. Métodos: O estudo incluiu 12 indivíduos com doença de Wilson e sintomas neurológicos (24 córneas). Doze córneas apresentavam clinicamente o anel clássico de Kayser-Fleischer e as outras 12 serviram como controle. Todos os pacientes foram submetidos a um exame clínico abrangente e a uma análise microestrutural subsequente utilizando microscopia confocal in vivo de varredura a laser. Os principais resultados observados foram: aumento da espessura da córnea, diminuição do número de células, aumento de resíduos/depósitos específicos e microestrutura atípica. Resultados: Clinicamente, todos os indivíduos com anel de Kayser-Fleischer (12 olhos) apresentaram achados similares da córnea e pressão intraocular normal. Dois indivíduos também apresentaram uma catarata de girassol típica e diminuição da acuidade visual. Todos os olhos do grupo controle apresentaram acuidade visual, pressão intraocular e aparência corneana normais. A microscopia confocal in vivo com varredura a laser revelou achados semelhantes em todas as córneas afetadas. O número de ceratócitos no estroma anterior era menor, 17.380/mm3 (22.380/mm3 no grupo controle), e entre eles foram identificadas áreas escuras arredondadas "vazias". Essas zonas escuras eram generalizadas e similares em todas as córneas examinadas e em todas as camadas da córnea. No estroma posterior periférico, havia presença de depósitos granulares brilhantes e com aparência de pó que tendiam a aumentar em número e densidade no sentido da membrana de Descemet, mascarando o endotélio periférico. As córneas controle apresentaram estrutura normal, com exceção de depósitos granulares com aparência de pó na periferia. Conclusões: A microscopia confocal in vivo é uma ferramenta útil para a avaliação da microestrutura da córnea quando o anel de Kayser-Fleischer está clinicamente presente. O anel é constituído de partículas granulares brilhantes com densidade aumentada no sentido da membrana de Descemet. Sua presença está associada com uma diminuição do número de ceratócitos e com áreas circulares escuras "peculiares" em todas as camadas estromais, que representam, provavelmente, um sinal de dano da córnea. Quando o anel não está clinicamente visível, a estrutura da córnea in vivo encontra-se insignificantemente alterada.

Depósitos de cálcio na córnea: estudo histopatológico / Calcium deposits in the cornea: histopathological study

Resumo Objetivo: Estudar, através do exame histopatológico, os depósitos de cálcio na córnea e suas diferentes formas de apresentação. Metodos: Estudo observacional, transversal, retrospectivo e descritivo de botões corneanos provenientes de ceratoplastia penetrante no período de 2006 a 2015. Coloração de rotina foi realizada com Hematoxilina-eosina, tendo sido realizadas em alguns casos as colorações adicionais: Masson, PAS (Periodic Acid of Schiff reaction) e reticulina. Os tecidos foram examinados com microscópio óptico pelos autores. Selecionamos apenas os casos em que foram identificados depósitos de cálcio no exame histopatológico. Após selecionados os casos, foi realizada revisão de prontuários em busca de informações sobre sexo, idade e etiologia do transplante. Resultados: Foram, então, incluídos 12 casos. As diferentes formas de apresentação dos depósitos de cálcio corneanos encontradas no exame histopatológico foram grânulos, placas e formações ovaladas ou suas associações. A principal forma de depósito foram os grânulos isolados ou associados em 9 (75%) casos, seguido pelas placas isoladas ou associadas em 8 (66,66% casos). A associação mais frequente encontrada foi de grânulos + placa em 5 (41,66%) casos , seguida por grânulos + formações ovaladas em 2 (16,66%) casos. A partir dos achados no exame histopatológico, foi proposta uma classificação e uma possível evolução dos depósitos de cálcio corneanos. Conclusão: Através do exame histopatológico, demonstramos as diferentes formas de apresentação dos depósitos de cálcio na córnea e, para eles, sugerimos uma possível evolução. Formação ovaladas foram descritas como uma nova forma de apresentação desses depósitos, que permanecem, porém, necessitando de uma melhor compreensão.

Abstract Objective: To study, through histopathological examination, calcium deposits in the cornea and its different presentation forms. Methods: Observational, transversal, retrospective and descriptive study of corneal buttons from penetrating keratoplasty from 2006 to 2015. Routine staining was performed with Hematoxylin-eosin, and in some cases additional staining was performed: Masson, PAS (Periodic Acid Of Schiff reaction) and reticulin. The tissues were examined with an optical microscope by the authors. We selected only the cases in which calcium deposits were identified in the histopathological examination. After the cases were selected, a chart review was carried out looking for information about sex, age and transplantation etiology. Results: Twelve cases were included. The different forms of corneal calcium deposits presentation found in the histopathological examination were granules, plaques and oval formations or their associations. The main form of deposition were isolated or associated granules in 9 (75%) cases, followed by isolated or associated plaques in 8 (66.66% cases). The most frequent association was granule + plaque in 5 (41.66%) cases, followed by granules + oval formations in 2 (16.66%) cases. From the findings in the histopathological examination, a classification and a possible evolution of the corneal calcium deposits was proposed. Conclusion: Through histopathological examination we demonstrate the different forms of calcium deposits presentation in the cornea and propose a possible evolution for them. Oval formations were described as a new presentation form for these deposits, which remain demanding a better understanding.

Corneal biomechanical features in patients with ankylosing spondylitis / Características biomecânicas da córnea entre pacientes com espondilite anquilosante

ABSTRACT Purpose: To evaluate the corneal biomechanical features and central corneal thickness in ankylosing spondylitis patients and to evaluate correlations of these parameters with disease activity. Methods: The study included 51 patients diagnosed with ankylosing spondylitis (mean age, 40.80 ± 13.15 years; range, 18-72 years) and 34 age- and sex-matched healthy controls (mean age, 42.00 ± 12.32 years; range, 18-60 years). All underwent a complete ophthalmological and physical examination, including visual acuity testing and biomicroscopic anterior and posterior segment examinations. Corneal hysteresis, corneal resistance factor, Goldmann-correlated intraocular pressure, and corneal compensated intraocular pressure were evaluated with an ocular response analyzer, and the central corneal thickness was measured with Sirius® corneal tomography. The Bath Ankylosing Spondylitis Disease Activity Index, Functional Index, and Metrology Index scores were recorded. Results: In the ankylosing spondylitis patients, the mean disease duration was 7.73 ± 6.05 (range, 1-30) years. There was no statistically significant difference between the patients and controls in the corneal biomechanical features. The Goldmann-correlated intraocular pressure and corneal compensated intraocular pressure both showed positive correlations with age (p=0.003 and p=0.001, res­pectively). There was a negative correlation between corneal hysteresis and disease duration (p=0.002), and between central corneal thickness and the Bath Ankylosing Spondylitis Metrology Index score (p=0.003). Conclusion: This study demonstrated a significant negative correlation between corneal hysteresis and disease duration in ankylosing spondylitis patients. Furthermore, the central corneal thickness value decreased with an increase in Bath Ankylosing Spondylitis Metrology Index score, which may result in an underestimate of intraocular pressure readings and thus an inaccurate risk assessment of glaucoma.

RESUMO Objetivo: Avaliar as características biomecânicas da córnea e espessura central da córnea em pacientes com espondilite anquilosante e analisar a correlação destes parâmetros no grupo de estudo com a atividade da doença. Métodos: Foram incluídos no estudo 51 pacientes com diagnóstico de espondilite anquilosante e 34 controles saudáveis com idade e sexo. Todos os sujeitos foram submetidos a um exame oftalmológico e físico completo, incluindo exames de acuidade visual, exames de segmento anterior e posterior biomicroscópicos. Foram avaliados o coeficiente de resistência da córnea, a pressão intraocular correlacionada com Goldmann e a pressão intraocular compensada da córnea com o analisador de resposta ocular, a espessura corneana central com a tomografia corneana pelo Sirius®. Se o índice de atividade da doença de espondilite anquilosante de banho, o índice funcional de espondilite anquilosante de banho, o índice de metrologia de espondilite anquilosante de banho. Resultados: Foram incluídos no estudo 51 pacientes com idade média de 40,80 ± 13,15 (intervalo: 18-72) anos e 34 casos de controle com idade média de 42,00 ± 12,32 (intervalo: 18-60) anos. No grupo espondilite anquilosante a duração média da doença foi de 7,73 ± 6,05 (1,00-30,00) anos. Não houve diferença estatisticamente significante entre dois grupos quanto às características biomecânicas da córnea. Na análise de correlação, no grupo de estudo; pressão intraocular correlacionada com Goldmann e pressão intraocular compensada da córnea estavam positivamente correlacionados com a idade (p=0,003, p=0,001, respectivamente). Houve uma correlação negativa entre a duração da doença e CH (p=0,002), e entre índice de metrologia de espondilite anquilosante de banho e espessura corneana central (p=0,003). Conclusão: Este estudo demonstrou correlação negativa significativa entre a duração da doença e a histerese corneal em pacientes com espondilite anquilosante. Além disso, com um aumento na pontuação de índice de metrologia de espondilite anquilosante de banho, o valor de espessura corneana central também estava di­minuindo o que pode causar uma diminuição nas leituras de pressão intraocular artificialmente e resultar em avaliação de risco imprecisa de glaucoma.

Surgical amniotic membrane transplantation after conjunctival and limbal tumor excision / Transplante de membrane amniótica após excisão de tumor limbar e conjuntival

ABSTRACT Purpose: To evaluate the clinical results of patients treated by amniotic membrane transplantation (AMT) following excision of conjunctival and limbal tumors. Methods: A total of 14 eyes of 14 patients who underwent AMT after total lesion-free tumor excision and perilesional cryotherapy were evaluated. Results: The excised tumors comprised 7 conjunctival intraepithelial neoplasia, 5 conjunctival nevus, 1 primary acquired melanosis, and 1 squamous cell carcinoma. Limbus was involved in 10 cases, whereas cornea was involved in 6 cases. The average measurement of the tumor base was 14.8 mm (range 6-20 mm, SD 16 mm). The mean follow-up time period was 17.5 months (range 6 -60 months, SD 20 months). Complete healing occurred in eight eyes, but limbal cell deficiency developed in two eyes. Four cases had recurrence and were treated with the same surgical and medical procedures; during follow-up after recurrence, superficial peripheral vascularization and corneal scar were noted to have developed. Conclusions: AMT was effective for reconstruction of tissue defect after excision and cryotherapy of limbal and conjunctival tumors. In most of these cases, complete healing was achieved with a smooth, stable, and translucent surface.

RESUMO Objetivo: Avaliar os resultados clínicos de pacientes tratados com transplante de membrana amniótica (TMA) após a excisão de tumores conjuntival e limbar. Métodos: Foram avaliados 14 olhos de 14 pacientes submetidos a transplante de membrana amniótica após excisão total de tumor e crioterapia perilesional. Resultados: Os tumores que foram excisados podem ser classificados como neoplasia intraepitelial conjuntival em 7, nevus conjuntival em 5, melanose adquirida primária e carcinoma espinocelular em 1 caso cada. O limbo foi envolvido em 10 casos e a córnea foi envolvida em 6 casos. A medida média da base do tumor foi de 14,8 mm (6-20, DP 16). O tempo médio de seguimento foi de 17,5 meses (6-60, DP 20). A cicatrização completa ocorreu em 8 olhos e deficiência de células limbares ocorreu em 2 olhos. A recorrência foi diagnosticada em 4 casos e tratada com o mesmo procedimento cirúrgico e médico e, após essa recorrência, a vascularização periférica superficial e a cicatriz corneana desenvolveram-se em 4 casos durante o seguimento. Conclusões: O transplante de membrana amniótica é um método eficaz para a reconstrução do defeito do tecido após a excisão de tumores limbares e conjuntivais com a combinação de crioterapia. Na maioria destes casos, a cicatrização completa pode ser conseguida com uma superfície lisa, estável e transparente.

Oculoectodermal syndrome: twentieth described case with new manifestations

Abstract Oculoectodermal syndrome is a rare disease characterized by the association of aplasia cutis congenita, epibulbar dermoids, and other abnormalities. This report describes the twentieth case of the disease. We report a 4-year-old female child who presented with the classical features of the syndrome: aplasia cutis congenita and epibulbar dermoids. Our case expands the clinical spectrum of the disease to include: diffuse hyperpigmentation (some following the Blaschko´s lines); hypopigmented skin areas on the trunk; arachnoid cyst on the right fronto-parietal border; rounded left side of the hippocampus; and dermoid cyst underlying the bulb-medullary transition. Our patient also reported infantile hemangioma on the right wrist and verrucous hemangioma on the left leg, the latter not previously described in the literature.

Excisão, crioterapia e mitomicina C no tratamento da neoplasia intraepitelial córneo-conjuntival / Excision, cryotherapy and mitomycin c for the treatment of conjunctival-corneal intraepithelial neoplasia

RESUMO Objetivo: Avaliar a segurança e eficácia de três técnicas distintas para o tratamento de neoplasia intraepitelial córneo-conjuntival. Métodos: Vinte e seis pacientes, 11 mulheres e 15 homens, com idade entre 32 e 88 anos (média 64,84 anos), atendidos entre 1999 e 2014, foram incluídos neste estudo. Todos os pacientes foram submetidos à exérese da lesão com margem de segurança de 4mm e crioterapia a 2mm do limbo. Conforme o tratamento complementar, os pacientes foram divididos em três grupos: Grupo 1 (8 olhos): recobrimento conjuntival e 2 ciclos de mitomicina C 0,02% (MMC) 4x/dia por 10 dias, com intervalo de 30 dias entre os ciclos. Grupo 2 (9 olhos): recobrimento com membrana amniótica e 3 ciclos de MMC 3x/dia por 10 dias, com intervalo de 10 dias entre o 1º e o 2º ciclo e 30 dias entre 2º e o 3º ciclo. Grupo 3 (9 olhos): recobrimento com membrana amniótica sem o uso de MMC. O acompanhamento dos pacientes variou de 3 meses a 14 anos (média: 4 anos). Resultados: Vinte e três pacientes apresentaram erradicação da lesão com um único tratamento. Três pacientes do Grupo 3 apresentaram recidiva da lesão após 3 meses, 6 meses e 1 ano do tratamento. Dois deles foram retratados pela técnica 1, sem nova recidiva após seguimento de 3 e 4 anos; o outro paciente foi submetido à enucleação. Não foram observados efeitos colaterais relacionados ao uso da mitomicina C durante o seguimento. Conclusão: Após exérese da lesão e crioterapia, os pacientes tratados com recobrimento conjuntival ou membrana amniótica associado à mitomicina C mostraram tendência a resultados mais eficazes.

ABSTRACT Purpose: To evaluate the safety and efficacy of three different techniques for the treatment of conjunctival-corneal intraepithelial neoplasia. Methods: Twenty-six eyes of 26 patients, 11 women and 15 men were included in a nonrandomized, retrospective, observational case series. Mean patient age was 64 years (range, 32-88 years).All patients were treated from 1999 to 2014. Mean postoperative follow-up was 4 years (range, 3 months to 14 years). All patients underwent excision of the lesion with a 4-mm safety margin and a 2-mm from the limbus cryotherapy. As further treatment the patients were divided into three groups: Group 1 (8 eyes): conjunctival autograft and 2 cycles of mitomycin C 0.02% (MMC) eye drops, four times daily for 10 days with an interval of 30 days between cycles. Group 2 (9 eyes): amniotic membrane (AM) graft and 3 cycles of MMC eye drops, three times daily for 10 days with an interval of 10 days between the 1st and 2nd cycle and 30 days between the 2nd and 3rd cycle. Group 3 (9 eyes): AM graft without MMC eye drops. Results: After a single treatment, the lesions were eradicated in twenty-three patients. Recurrence was noted in three patients from Group 3 at 3 months, 6 months and 1 year after treatment. Two of them were retreated by the technique used in Group 1 without further recurrence; the other patient underwent enucleation. No adverse effects related to the use of mitomycin C were observed during. There were no side effects related to the use of mitomycin C during follow-up. Conclusion: After surgical excision and cryotherapy, patients treated with conjunctival or amniotic membrane graft associated with mitomycin C, showed a tendency to more effective results.

A linfangiogênese em enxertos corneanos humanos que evoluem para retransplante / Lymphangiogenesis in human corneal grafts that has evolved to re-transplantation

RESUMO Objetivo: Estudar botões corneanos humanos com linfangiogênese através do exame histopatológico, juntamente com os enxertos de seus transplantes anteriores e posteriores, avaliando os intervalos de tempo para sucessivas cirurgias. Métodos: Estudo descritivo, observacional, longitudinal de botões corneanos humanos com linfangiogênese, juntamente com seus transplantes anteriores e posteriores. Os tecidos foram provenientes de ceratoplastia penetrante no período compreendido entre os anos 2006 e 2013. Após revisão de prontuários em que foram obtidas principalmente as datas das cirurgias, construímos uma tábua de sobrevivência a partir da qual os intervalos de tempo para retransplante foram calculados. Resultados: Entre 89 casos de linfangiogênese corneana, foram incluídos apenas aqueles 22 que possuíam registros no prontuário de transplantes anteriores ou posteriores. Nos casos que apresentavam como provável etiologia do retransplante a linfangiogênese, isolada ou associada à hemangiogênese (grupos pré-linfangiogênese/linfangiogênese e interlinfangiogênese), foram encontrados intervalos de tempo para retransplante menores (7 e 3 meses, respectivamente) que aquele encontrado no grupo linfangiogênese/pós-linfangiogênese que apresentava outras etiologias prováveis para os retransplantes (11,31 meses). Casos que apresentavam como etiologia provável do retransplante a linfangiogênese isolada apresentaram um intervalo para retransplante (3 meses) ainda menor que aquele encontrado nos casos em que a etiologia provável era a linfangiogênese associada à hemangiogênese (7,80 meses). Conclusão: Linfangiogênese, isolada ou associada à hemangiogênese, foi encontrada nos enxertos corneanos humanos estudados que evoluíram para retransplante em pequenos intervalos de tempo. Esse achado nos leva a sugerir um possível papel para os vasos linfáticos na redução do tempo de sobrevida dos enxertos corneanos humanos.

ABSTRACT Objective: To study human corneal buttons with lymphangiogenesis through histopathological examination, together with the grafts of their preceding and subsequent transplantations, evaluating the time intervals for successive surgeries Methods: A descriptive, observational and longitudinal study of human corneal buttons that have lymphatic vessels, together with its preceding and subsequent transplants. Tissues were obtained from penetrating keratoplasty in the period between the years 2006 and 2013. After a medical records review in which information on the dates of the surgeries were mainly obtained, we built a survival table from which the time intervals for retransplantation were calculated. Results: Among 89 cases of corneal lymphangiogenesis, we included only those 22, which had previous or subsequent transplantations records in medical records. In cases where the probable regrafting etiology were lymphangiogenesis, alone or combined with hemangiogenesis (pre-lymphangiogenesis/lymphangiogenesis and interlymphangiogenesis groups), time intervals for retransplantation were found to be minor (7 and 3 months, respectively) than that found in lymphangiogenesis/post-lymphangiogenesis group that had other probable etiologies for retransplantations (11.31 months). Cases that had isolated lymphangiogenesis as probable etiology of retransplantation showed an interval time for retransplantation (3 months) lower than that found in cases in which the probable etiology was lymphangiogenesis associated with hemangiogenesis (7.80 months). Conclusion: Lymphangiogenesis, alone or combined with hemangiogenesis, was found in human corneal grafts studied that have evolved to regraft in small time intervals. This finding leads us to suggest a possible role for the lymphatic vessels in reducing the human corneal grafts survival time.

Deep Anterior Lamellar Keratoplasty Using Irradiated Acellular Cornea with Amniotic Membrane Transplantation for Intractable Ocular Surface Diseases

PURPOSE: To report the clinical outcomes of deep anterior lamellar keratoplasty (DALK) when sterile gamma-irradiated acellular corneal tissues (VisionGraft) are used in combination with amniotic membrane transplantation (AMT) for intractable ocular surface diseases. METHODS: The medical records of fifteen patients who had DALK with AMT were retrospectively reviewed. Indications for surgery included ocular burn, bacterial keratitis, herpes simplex virus keratitis, corneal opacity with Stevens-Johnson syndrome, Mooren's ulcer, idiopathic myxoid degeneration of corneal stroma, and recurrent band keratopathy. DALK was performed using partial-thickness acellular corneal tissue and a temporary amniotic membrane patch was added at the end of the operation. RESULTS: All cases that underwent DALK with AMT became epithelialized within 2 postoperative weeks. Twelve patients showed favorable outcomes without graft rejection, corneal opacification, or neovascularization. The other three grafts developed corneal opacification and neovascularization, and required additional penetrating keratoplasty (PK). Unlike the results of previous PKs, there were no graft rejections and the graft clarity was well-maintained in these three cases for at least 8 months after PK. CONCLUSIONS: DALK using sterile acellular corneal tissues in combination with AMT may be a good therapeutic strategy for treating intractable ocular surface diseases because of lowered immune rejection, fibroblast activation, and facilitation of epithelialization. Furthermore, DALK can help stabilize the ocular surface, prolong graft survival, and may allow better outcomes when combined with subsequent PK.

Achados histopatológicos em 431 córneas de receptores de transplantes no Rio de Janeiro / Histopathology finds in 431 corneas from transplant receptors in Rio de Janeiro

Foram examinadas 431 córneas de receptores de transplantes no Rio de Janeiro recebidas em sua maioria do Banco de Olhos associado à Sociedade Brasileira de Oftalmologia (SBO) e, as últimas, do Rio-transplante, após o fechamento temporário do Banco de Olhos. É notável a diferença entre os percentuais e o ordenamento das principais causas de transplante achadas neste levantamento, todos por comprovação histopatológica dos diagnósticos, e as citadas em bibliografia encontradas em Sorocaba, Porto Alegre, Florianópolis, Manaus e Recife baseadas apenas no levantamento dos prontuários clínicos.

Four hundred and thirty one cornea from transplant receptors in Rio de Janeiro were analised, most of them received from Banco de Olhos, associated to Brazilian Society of Ophtalmology (SBO) and from Rio-transplante, after temporary closing of Banco de Olhos. There is a markable difference between the percentual and incidence from the most important causes founded in this work, all of them prooved by histopathology, and the causes reported in bibliography at Sorocaba, Porto Alegre, Florianópolis, Manaus and Recife, based only in clinical archives.

Effects of Argon Laser Iridotomy on the Corneal Endothelium of Pigmented Rabbit Eyes

PURPOSE: In Asian countries, laser iridotomy for the treatment of angle-closure glaucoma is a common cause of bullous keratopathy, which may be associated with a shallow anterior chamber and dark iris pigmentation in Asians. Several cases of corneal decompensation after argon laser iridotomy have been reported. In the present study, we evaluated the harmful effects of argon laser iridotomy on the corneal endothelium. METHODS: Argon laser iridotomy was performed on the right eyes of pigmented rabbits. Changes in corneal thickness and endothelial cell density after laser iridotomy were evaluated. Terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) was performed for assessment of corneal endothelial cell apoptosis. Combined staining with alizarin red and trypan blue, as well as a live/dead cell assay, were performed for evaluation of damage to the corneal endothelium induced by laser iridotomy. RESULTS: Corneal thickness did not change immediately after laser iridotomy; however, a significant increase was observed 24 hours after iridotomy (p = 0.001). The endothelial cell density of laser-treated eyes four days after laser iridotomy was significantly decreased compared with control eyes (p < 0.001). TUNEL staining showed many TUNEL-positive cells in the corneal endothelium and corneal stroma. No endothelial trypan blue-stained cell nuclei were observed after laser iridotomy; however, several large endothelial cells with damaged membrane integrity were observed. The live/dead cell assay clearly showed a large number of dead cells stained red in several areas throughout the entire corneal button 24 hours after iridotomy. CONCLUSIONS: Argon laser iridotomy induces corneal endothelial cell apoptosis in pigmented rabbit eyes, resulting in decreased endothelial cell density.

Effects of Argon Laser Iridotomy on the Corneal Endothelium of Pigmented Rabbit Eyes

PURPOSE: In Asian countries, laser iridotomy for the treatment of angle-closure glaucoma is a common cause of bullous keratopathy, which may be associated with a shallow anterior chamber and dark iris pigmentation in Asians. Several cases of corneal decompensation after argon laser iridotomy have been reported. In the present study, we evaluated the harmful effects of argon laser iridotomy on the corneal endothelium. METHODS: Argon laser iridotomy was performed on the right eyes of pigmented rabbits. Changes in corneal thickness and endothelial cell density after laser iridotomy were evaluated. Terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) was performed for assessment of corneal endothelial cell apoptosis. Combined staining with alizarin red and trypan blue, as well as a live/dead cell assay, were performed for evaluation of damage to the corneal endothelium induced by laser iridotomy. RESULTS: Corneal thickness did not change immediately after laser iridotomy; however, a significant increase was observed 24 hours after iridotomy (p = 0.001). The endothelial cell density of laser-treated eyes four days after laser iridotomy was significantly decreased compared with control eyes (p < 0.001). TUNEL staining showed many TUNEL-positive cells in the corneal endothelium and corneal stroma. No endothelial trypan blue-stained cell nuclei were observed after laser iridotomy; however, several large endothelial cells with damaged membrane integrity were observed. The live/dead cell assay clearly showed a large number of dead cells stained red in several areas throughout the entire corneal button 24 hours after iridotomy. CONCLUSIONS: Argon laser iridotomy induces corneal endothelial cell apoptosis in pigmented rabbit eyes, resulting in decreased endothelial cell density.

Impression cytology and in vivo confocal microscopy in corneas with total limbal stem cell deficiency / Citologia de impressão e microscopia confocal in vivo em córneas com deficiência total das células-tronco do limbo

PURPOSES: To describe corneal changes seen on in vivo confocal microscopy in patients with total limbal stem cell deficiency and to correlate them with cytological findings. METHODS: A prospective case series including 13 eyes (8 patients) with total limbal deficiency was carried out. Stem cell deficiency was diagnosed clinically and by corneal impression cytology. Confocal images of the central cornea were taken with the Heidelberg Retina Tomograph II, Rostock Corneal Module (Heidelberg Engineering, Heidelberg, Germany). RESULTS: Impression cytology of the cornea revealed conjunctival epithelial cells and goblet cells in all cases. In vivo confocal microscopy showed disruption of normal layers of the corneal epithelium in all eyes. Confocal images showed cells with characteristics of conjunctival epithelium at the cornea in 76.9% of the total. These findings on confocal microscopy were compatible to limbal stem cell deficiency. Additionally, goblet cells, squamous metaplasia, inflammatory cells and dendritic cells were observed. The sub-basal nerve plexus was not identified in any of the corneas. Corneal neovessels were observed at the epithelium and stroma. All cases showed diffuse hyper-reflective images of the stroma corresponding to opacity of the tissue. CONCLUSIONS: Limbal stem cell deficiency had been confirmed by impression cytology in all cases, and 76.9% of the cases could also be diagnosed by in vivo confocal microscopy through the conjunctival epithelial cell visualization on the corneal surface. Frequent confocal microscopy findings were abnormal cells at the cornea (conjunctival epithelial, goblet and inflammatory cells), corneal neovessels and diffuse hyper-reflection of the stroma.

OBJETIVOS: Descrever as alterações corneais observadas na microscopia confocal in vivo e relacioná-las aos achados da citologia de impressão em pacientes com deficiência total das células-tronco do limbo. MÉTODOS: Série de casos prospectiva incluindo 13 olhos (8 pacientes) com deficiência total das células-tronco do limbo. A deficiência límbica foi diagnosticada clinicamente e mediante citologia de impressão da córnea. Imagens confocais da córnea central foram obtidas com o Heidelberg Retina Tomograph II, Rostock Corneal Module (Heidelberg Engineering, Heidelberg, Alemanha). RESULTADOS: A citologia de impressão da córnea demonstrou células epiteliais da conjuntiva e células caliciformes em todos os casos. A microscopia confocal da área central da córnea mostrou alteração da estrutura normal das camadas do epitélio corneal em todos os casos. As imagens confocais da córnea mostraram a presença de células com características do epitélio conjuntival em 76,9%. Esses achados no exame confocal são compatíveis com deficiência das células-tronco do limbo. Adicionalmente, células caliciformes, metaplasia escamosa, células inflamatórias e dendríticas foram observadas. O plexo nervoso sub-basal não foi identificado em nenhum dos casos. Neovasos corneais foram observados no epitélio e no estroma. Em todos os casos havia imagens difusamente hiperreflectivas no estroma, correspondendo à opacidade do tecido. CONCLUSÕES: A deficiência das células-tronco do limbo, previamente confirmada por citologia de impressão, pôde ser demonstrada pela microscopia confocal in vivo em 76,9% dos casos através da visualização de células epiteliais da conjuntiva na córnea. Achados frequentes na microscopia confocal foram células anormais na córnea (células conjuntivais, caliciformes e inflamatórias), neovasos corneais e hiperreflexão difusa do estroma.

Autologous Tragal Perichondrium Transplantation: A Novel Approach for the Management of Painful Bullous Keratopathy

PURPOSE: To introduce autologous tragal perichondrium transplantation as a novel surgical modality for the management of intractable symptomatic bullous keratopathy. METHODS: In three eyes of three patients with painful bullous keratopathy, autologous tragal perichondria were transplanted on the corneal surface with the human amniotic membrane transplanted above. We included an additional three eyes of three patients with painful bullous keratopathy who received amniotic membrane transplantation only to serve as controls. Clinical symptom outcomes were assessed using a visual analogue scale at postsurgical months 1, 3, 5, 7, and 9. In addition, transplanted tragal perichondrium and amniotic membrane complex tissue button obtained from one patient who underwent penetrating keratoplasty was evaluated by immunohistochemical analysis of CD34, vimentin, and alcian blue staining. RESULTS: All three patients who underwent autologous tragal perichondrium and human amniotic membrane co-transplantation showed improvements in pain and tearing. However, all three patients in the control group experienced aggravation of tearing and no further improvement of pain 3 months after surgery. In addition, one patient in the control group developed premature degradation of the amniotic membrane. Histopathologic and immunohistochemical analysis showed intact surface epithelization and positive CD34, vimentin and alcian blue staining of transplanted tragal perichondria. CONCLUSIONS: The tragal perichondrium has a high mechanical structural force and high potency due to well-organized epithelization and the presence of mesenchymal stem cells. Autologous tragal perichondrium transplantation may be an effective modality for the management of painful bullous keratopathy.

Sphingosine-1 phosphate prevents ethanol-induced corneal epithelial apoptosis.

Background: Apoptosis is a programmed cell death in multicellular organisms, found in a wide variety of conditions, including inflammatory process, everywhere in the body, including the cornea and conjunctiva. Aim: To evaluate the effect of a new topical formulation of sphingosine-1 phosphate on preventing apoptosis of the corneal epithelium. Setting: Medical University. Materials and Methods: We tested several formulations suitable for topical application. Twenty-five rabbits were distributed among five groups. Group 1 comprised the controls. In Group 2, 20% ethanol was applied topically for 20 seconds; in Group 3, 50 μM topical sphingosine-1 phosphate was applied 2 hours prior to 20% ethanol application. In Group 4, 200 μM topical sphingosine-1 phosphate was applied 2 hours before the 20% ethanol application. In Group 5, only 200 μM topical sphingosine-1 phosphate was applied. Apoptosis was evaluated using the terminal deoxynucleotidyl transferase biotin-dUTP Nick End Labeling (TUNEL) assay. Pairwise comparisons were performed using t-tests with Scheffe's correction. Data were analyzed using STATA 9.0 statistical software. Results: A suspension of sphingosine-1 phosphate in the presence of Montanox 80 was stable and could be formulated without sonication. Epithelial apoptosis was detected only in Groups 2 and 3. Conclusion: Sphingosine-1 phosphate can prevent ethanol-induced apoptosis in the corneal epithelium of rabbits.

Short-term outcome of Boston Type 1 keratoprosthesis for bilateral limbal stem cell deficiency.

This study reports the short-term functional and anatomical outcome of Boston Type 1 keratoprosthesis (Boston Kpro) implantation for bilateral limbal stem cell deficiency (LCSD). Retrospective analysis was done on eight eyes of eight patients who underwent Boston Kpro implantation between July 2009 and October 2009. The best corrected visual acuity (BCVA) and slit-lamp biomicroscopy findings were assessed at 1, 3 and 6 months postoperatively. All eight eyes retained the prosthesis. BCVA of 20/40 or better was achieved in 8, 6, and 5 eyes at 1, 3, and 6 months, respectively, postoperatively. One patient each developed epithelial defect, sterile stromal melt and fungal keratitis in the late postoperative period associated with antecedent loss of the soft contact lens from the eye. Boston Kpro has good short-term visual and anatomical outcome in patients with bilateral LSCD, provided compliance with postoperative care can be ensured.

Outcome of optical penetrating keratoplasties at a tertiary care eye institute in Western India.

Aim: To study the indications, risk factors, postoperative course, and long-term survival of corneal transplants done for optical purposes. Design: Retrospective case series. Materials and Methods: Data were obtained by reviewing the records of 181 patients operated at our institute (H.V. Desai Eye Hospital) between October 2005 and October 2007 for optical penetrating keratoplasty. Patients with less than one year of follow up, pediatric cases, therapeutic, tectonic, and lamellar keratoplasties were excluded. Kaplan Meier survival analysis was used to calculate median survival time of grafts and to see correlation between nine variables viz. age, gender, corneal vascularization, previous failed grafts, previous Herpes Simplex keratitis, post-perforation corneal scars, donor tissue quality, graft size, type of surgery and follow-up. These variables were also used for univariate and multivariate analysis using Cox Proportional Hazard Regression Modeling. Results: Median survival of the cohort was 27 months (95% confidence interval: 20.47-33.52). One- and two-year survival rates were 65% and 52.5%, respectively. Median survival was significantly lower in poor prognosis cases (14 months) than good prognosis cases (27 months, P = 0.0405). Graft survival was lower in vascularized corneas (18.55 months, P = 0.030) and in post-perforation corneal scars (17.96 months, P = 0.09, borderline significance). Multivariate analysis showed that the same factors were predictive of graft failure. Conclusion: Long-term survival of grafts at our center is different from centers in western world. More high-risk cases, paucity of excellent quality donor corneas, and differences in patient profile could be the contributory factors.

Role of anterior segment optical coherence tomogram in Descemet's membrane detachment.

Descemet's membrane detachment (DD) is a rare but serious complication of intraocular surgery. In rare cases where corneal edema is severe and we may not be able to visualize DD on slit-lamp examination, anterior segment optical coherence tomogram (AS-OCT) would be helpful. We describe two patients with DD, highlighting the role of AS-OCT in early diagnosis and management of patients with DD. One of the patients had DD with rolled in edge, which could only be visualized with AS-OCT. In such a situation, AS-OCT can identify the edge of detachment and show the exact position of the rolled edge, which can allow us to plan the surgical strategy to unroll the DD.

Confocal scan features of keratic precipitates in granulomatous versus nongranulomatous uveitis

To compare the morphologic features of keratic precipitates [KPs] by confocal microscopy in granulomatous versus nongranulomatous noninfectious uveitis. KP morphology was determined by confocal scan in patients with noninfectious granulomatous and noninfectious nongranulomatous uveitic cases. One hundred and twenty-seven eyes of 90 subjects with noninfectious uveitis were studied. Thirty-nine eyes had granulomatous and 88 had nongranulomatous uveitis. Smooth-rounded KPs were significantly more common in the granulomatous subgroup [P<0.001] while cruciform and dendritiform KPs were more frequent in nongranulomatous uveitis [P<0.001 and P<0.005 respectively]. Confocal scan may be used as an adjunctive tool for differentiating granulomatous from nongranulomatous uveitis. Smooth-rounded KPs are strongly suggestive of granulomatous inflammation

Captura híbrida negativa em displasia intraepitelial isolada de córnea / Negative hybrid capture in a single intraepithelial corneal dysplasia

As displasias intraepiteliais de córnea correspondem a lesões de baixo risco de malignidade, dentro do espectro das neoplasias intraepiteliais da superfície ocular. Essas displasias se apresentam como áreas leucoplásicas e têm como um dos principais fatores de risco o papilomavírus humano (HPV). No presente trabalho, os autores descrevem um caso de displasia intraepitelial isolada de córnea, tratada através de excisão cirúrgica, com confirmação histológica e resultado negativo de hibridização de DNA para HPV.

Cornea intraepithelial dysplasias are lesions with low risk of malignancy within the spectrum of intraepithelial neoplasia of the ocular surface. These areas are presented as dysplasias or leukoplasias and are associated with the presence of human papillomavirus (HPV), a major risk factor. In this report, the authors describe a case of a corneal intraepithelial dysplasia treated by surgical excision, with histological confirmation and negative DNA hybridization for HPV.