First 100: learning curve for Descemet stripping automated endothelial keratoplasty.

PURPOSE: Endothelial keratoplasty is largely replacing penetrating keratoplasty for the routine treatment of corneal endothelial failure. The aim of the study was to describe the performance, complications, and outcome of the first 100 Descemet stripping automated endothelial keratoplasty (DSAEK) procedures performed at a major medical center, with an emphasis on the learning curve. 
 METHODS: A retrospective, comparative case series study was conducted by a single surgeon at a tertiary, university-affiliated medical center. Data were collected on 100 consecutive DSAEK procedures performed between September 2008, when the technique was introduced in the ophthalmology department, and January 2011. Main outcome measures include best-corrected visual acuity, graft dislocation rate, primary failure rate, and endothelial cell loss. Findings were compared between the first (early group) and last (late group) 50 cases.
 RESULTS: Mean (SD) logMAR best-corrected visual acuity at 1 year improved from 1.02 ± 0.36 to 0.38 ± 0.35 in the early group (p<0.05) and from 0.93 ± 0.48 to 0.25 ± 0.21 in the late group (p<0.05) (n = 86). Although the late group included more complex cases (presence of anterior chamber intraocular lens, need for combination cataract surgery or secondary scleral intraocular lens fixation), graft dislocation was more common in the early group (20% versus 10%, p = 0.26). Primary and late graft failures occurred only in the early group (12% vs 0, p = 0.03). 
 CONCLUSIONS: Rates of primary failure and disc dislocation for DSAEK decrease as surgeons gain experience with the procedure, and the number of functional grafts increases accordingly. Visual outcome improves regardless of surgical experience.

The use of ophthalmic viscosurgical devices during donor's corneal harvesting.

PURPOSE OF THE STUDY: To evaluate the protective effect of Biolon (sodium-hyaluronate 1%) use on corneal endothelium, during donor's corneal harvesting. MATERIALS AND METHODS: A prospective, randomized, double blind, comparative study was performed on 120 corneas donated from 60 donors. One cornea from each donor (n = 60) was harvested using intracameral injection of ophthalmic viscosurgical device (OVD), and the fellow cornea with no use of OVD (n = 60, control group). Endothelial cell density (ECD) values were obtained at the center of each corneal graft with a specular microscope one day after harvesting. RESULTS: ECD in the OVD group were 2839 ± 412.5 cells/mm(2) and in the control group 2748 ± 429.7 cells/mm(2). (p = 0.03). Distribution curve of the difference in ECD between the OVD and no OVD eyes showed that 47% of the donors had > 100 cells/mm2 difference, and 32% of donors had >200 cells/mm(2) difference in favor of the OVD group. CONCLUSIONS: Intracameral OVD injection during corneal graft harvesting may protect the endothelium from the mechanical damage induced during the procedure. Further investigation is needed before routine the use of intracameral OVD should be considered in this setting.

Intravitreal bevacizumab treatment for exudative age-related macular degeneration with good visual acuity.

PURPOSE: To investigate the effect of intravitreal bevacizumab on the visual and anatomic outcome of patients with exudative age-related macular degeneration presenting with good visual acuity (VA). METHODS: A file review was performed for all consecutive patients with newly diagnosed exudative age-related macular degeneration and initial VA of ≥ 20/40 treated in 2005 to 2010 and followed for at least 6 months. Treatment consisted of 3 loading doses of intravitreal bevacizumab every 6 weeks and was repeated when fluid or hemorrhage was present. RESULTS: The cohort included 130 patients (150 eyes). Mean follow-up was 20.2 ± 13.2 months, and mean number of injections was 11.3 ± 6.2. At the last examination, VA was stable or improved in 106 eyes (70.7%); 11 eyes (7.3%) lost ≥ 3 lines. Mean logarithm of the minimum angle of resolution VA measured 0.22 ± 0.1 (0-0.3) at presentation and 0.22 ± 0.2 (0-1.3) at the last visit. Corresponding values for central macular thickness were 267 ± 75 µm (137-562) and 226 ± 75 µm (75-568) (P = 0.14). The most frequent complication (18 eyes, 12%) was corneal epithelial defects. CONCLUSION: Prompt intravitreal bevacizumab treatment for newly diagnosed exudative age-related macular degeneration in patients with good initial best-corrected visual acuity is associated with sustained or improved vision and a good safety profile. Attempts should be made to expedite the access of these patients to treatment, regardless of initial VA.

Intravitreal bevacizumab treatment for macular edema due to branch retinal vein occlusion in a clinical setting.

PURPOSE: To report the functional and anatomical outcome of intravitreal bevacizumab (IVB) treatment for macular edema due to branch retinal vein occlusion (BRVO) in a clinical setting. METHODS: The files of 45 patients treated with IVB for BRVO-induced macular edema at a tertiary medical center in 2007-2010 were reviewed. All received three loading doses (1.25 mg) and were followed every 6 weeks. Treatment was repeated for persistent or recurrent edema. If the edema did not resolve after 4-6 injections, grid laser photocoagulation was performed. RESULTS: Mean patient age was 70.7 years (SD 8.5); mean follow-up time, 18.8 months (SD 8.3); mean number of injections, 8.8 (SD 3.8). Fourteen patients (33%) received grid laser treatment before bevacizumab and 23 (51%) after. Mean logMAR visual acuity (VA) was 0.63 (SD 0.43) before treatment (Snellen, 20/140) and 0.4 (SD 0.43) (Snellen, 20/70) after (p < 0.0005). Corresponding central macular thickness (CMT) values were 382.2 microns (SD 155.6) and 320.5 microns (SD 172.8) (p= 0.028). Positive correlations were found between initial VA and initial and final CMT (p = 0.004) and between gain in VA and reduction in CMT (p = 0.03). There was no statistically significant difference in mean initial or final VA and CMT between patients who received grid laser treatment before or during the study and those who did not. CONCLUSIONS: IVB treatment improves visual function and reduces CMT in patients with BRVO-induced macular edema.

Intravitreous bevacizumab treatment for macular edema due to central retinal vein occlusion.

PURPOSE: To investigate the visual and anatomical effects of intravitreal bevacizumab treatment of macular edema due to central retinal vein occlusion (CRVO). METHODS: Data were collected by medical chart review for 35 consecutive patients (35 eyes) with CRVO-induced macular edema treated with intravitreal bevacizumab in 2007-2010 and followed for at least 6 months. All patients received 3-4 loading doses (1.25 mg) with follow-up every 6-8 weeks and repeated injections as necessary. RESULTS: Mean patient age was 65.5 years (SD 13.5); mean follow-up time, 17.7 months (SD 10.8); mean number of injections, 9.3 (SD 5). Mean logMAR visual acuity (VA) improved from 0.9 (SD 0.49) at baseline to 0.7 (SD 0.5) at the last visit; corresponding Snellen values were 6/98 and 6/15 (p = 0.009). Four patients (11%) lost ≥3 lines, and 13 patients (37%) gained ≥3 lines. There was a positive correlation between initial and final VA (p < 0.0005). Central macular thickness (CMT) measured 489.5 microns (SD 175) at baseline and 395 microns (SD 223) at the last visit (p = 0.24). VA gain was positively correlated with CMT reduction (p < 0.0001). CONCLUSIONS: Intravitreal bevacizumab treatment of CRVO-induced macular edema improves vision, especially in patients with good initial VA.

Endophthalmitis and wound dehiscence following late removal of penetrating keratoplasty sutures.

BACKGROUND AND OBJECTIVE: The patient characteristics, risk factors, and outcome of penetrating keratoplasty (PK) wound dehiscence following late suture removal. PATIENTS AND METHODS: Retrospective review of 207 cases of PK performed between 2005 and 2007 in Beilinson Hospital, Israel. RESULTS: Analysis of 207 patients who underwent PK revealed 4 cases (an incidence of 1.93%) that developed spontaneous wound dehiscence with severe endophthalmitis following late suture removal. Mean time from transplantation to suture removal was 22.18 months (range: 18 to 26 months). The time from suture removal to endophthalmitis was on average 2.25 weeks. All patients underwent vitrectomy with injection of intraocular antibiotics. The causative microorganism was found to be Streptococcus species in three patients and Staphylococcus epidermidis in one patient. One patient retained a clear corneal graft, another patient is scheduled for repeat PK, and the last two patients lost sight (50%). CONCLUSION: Endophthalmitis and wound dehiscence following late suture removal after PK are rare complications, but the end result can be devastating to the transplanted eye when they do occur. Careful monitoring and close follow-up can aid in early identification and treatment of such complications and may prevent loss of sight. Newer methods of corneal transplantation, such as Descemet's stripping automated endothelial keratoplasty or Descemet's membrane endothelial keratoplasty, should be considered as a better alternative to PK whenever the case qualifies as such.

Outcomes and complications of rhegmatogenous retinal detachment repair with selective sutureless 25-gauge pars plana vitrectomy.

PURPOSE: To evaluate the outcomes and complications associated with the repair of rhegmatogenous retinal detachment (RRD) using 25-gauge pars plana vitrectomy (PPV) with selective sclerotomy suturing. DESIGN: Retrospective case series. METHODS: Analysis of consecutive 25-gauge pars plana vitrectomy cases performed for treating RRD was conducted. Reviewed parameters included demographics, ophthalmic history, results of ocular examinations, and intraoperative as well as postoperative complications. Analysis of the surgery digital video disc recordings revealed complications such as iatrogenic retinal breaks and retinal or subretinal tugging by the soft-tip cannula. RESULTS: Forty-two eyes with RRD were evaluated with a follow-up of at least 3 months. The preoperative best-corrected visual acuity (BCVA) of 20 eyes with macula-on RRD ranged between 20/20 and 20/40 (mean, 20/30). Twenty-two eyes with macula-off RRD had preoperative BCVA ranging between 20/70 and hand movements (mean, 20/400). The single-surgery success rate was 97.4%. The final BCVA of the macula-on eyes ranged between 20/20 and 20/40 (mean, 20/30). In the eyes with macula-off RRD, the postoperative BCVA ranged between 20/30 and 20/400 (mean, 20/73). Sutures were placed on at least 1 scleral wound because of intraoperative gas leakage in 36.4% of the eyes. On the first postoperative day, all the eyes receiving gas tamponade had a 100% fill. None of the eyes in the study had postoperative hypotony, ciliochoroidal effusion, or choroidal hemorrhage. No cases of postoperative subconjunctival gas or oil leakage were noted. CONCLUSIONS: Modification of the standard 25-gauge sutureless technique with selective scleral wound suturing may contribute to preventing wound leakage and possible postoperative complications of hypotony or partial tamponade.