[Corneal endothelial cell loss after phacoemulsification in relation to hydrodynamic parameters: low versus high vacuum techniques]

To evaluate the effect of vacuum and flow rate on endothelial cell loss after high versus low vacuum phacoemulsification. This randomized clinical trial was performed on 60 eyes of 60 patients with moderate lens opacity [nuclear sclerosis 3+]. All surgeries were performed by one experienced surgeon using stop and chop technique with Sovereign white star machine [AMO]. Patients were randomly assigned to high and low vacuum techniques in equal numbers. The machine was set on 400 mmHg vacuum and 40 ml/min flow rate in the high vacuum group and on 200 mmHg vacuum and 20 ml/min flow rate in the low vacuum group during the chop stage. All other parameters were similar in both groups. Phacotime multiplied by average ultrasound power was defined as total ultrasound energy. Specular microscopy was performed before and 1, 6 and 12 weeks after the operation. After 12 weeks, mean endothelial cell loss was 9.0 +/- 4.0% versus 9.6 +/- 4.6% in the low and high vacuum groups, respectively [P=0.6]. Mean ultrasound power was 9.2 +/- 4.3% and 13.1 +/- 4.6% in the low and high vacuum groups, respectively [P=0.001]. Mean phacotime was 1.28 +/- 1.0 minutes in the low vacuum group versus 0.88 +/- 0.6 minutes in the high vacuum group [P=0.04]. Total ultrasound energy and total fluid volume used [turbulence] during phacoemulsification was similar between the two study groups. Total ultrasound energy was the most powerful predictor of endothelial cell loss [R2=0936, P=0.001], but turbulence was not a significant predictor [R2=0.924, P=0.1]. No significant difference in endothelial cell loss was found between low and high vacuum techniques. This study supports advice to junior surgeons to choose lower hydrodynamic phaco machine parameters; experienced surgeons can choose higher parameters to reduce phacotime

[Candida interface keratitis after deep anterior lamellar keratoplasty: clinical, microbiologic, histopathologic and confocal microscopic reports]

To report the clinical, histopathologic, microbiologic and confocal microscopic features of Candida keratitis after deep anterior lamellar keratoplasty [DALK]. The first patient presented with asymptomatic white to cream-colored interface deposits two months after DALK. Confocal scan disclosed clusters of hyper-reflective fine granular deposits in the interface with no evidence of inflammation or hypha-like structures. With a presumptive clinical diagnosis of progressive epithelial down-growth, irrigation of the interface was performed. Finally, penetrating keratoplasty was performed due to rupture in the Descemet's membrane. Histopathologic examination of the cornea disclosed yeast-like structures at the interface area. Microbiologic results of the irrigation fluid demonstrated Candida glabrata. The second patient presented with symptomatic infiltration of the inferior interface close to the suture site 2.5 months after DALK. Confocal scan disclosed foci of inflammation with clusters of hyper-reflective roundshaped structures that resembled epithelial cells. With a clinical diagnosis of epithelial down growth and progression of the lesion, penetrating keratoplasty was performed. Histopathologic examination of the cornea revealed acute and chronic granulomatous keratitis due to yeast-like structures. The microbiologic results demonstrated infection with Candida albicans. Clinical and confocal features of interface Candida keratitis may resemble those of epithelial down-growth, which may postpone correct diagnosis and treatment. Candida keratitis should be considered in cases of interface deposits after any form of lamellar keratoplasty