Comparison of Long-Term Outcomes of DSEK and DMEK in Fuchs Endothelial Dystrophy.

PURPOSE: This study aimed to compare the long-term endothelial cell loss, graft survival, and clinical outcomes in patients with Fuchs endothelial dystrophy (FED) after Descemet stripping endothelial keratoplasty (DSEK) and Descemet membrane endothelial keratoplasty (DMEK) using a standardized surgical protocol. METHODS: Three hundred and six consecutive DSEK and DMEK grafts of 223 patients with FED performed by 8 surgeons between January 2006 and August 2022 were analyzed. The primary outcome measures were graft survival, endothelial cell loss, and best spectacle-corrected visual acuity. RESULTS: At 5 years, graft survival was 96% for both DSEK and DMEK eyes. The mean percentage of endothelial cell loss was 57.7 ± 17.1 in DSEK and 56.8 ± 15.2 in DMEK eyes ( P = 0.430). The mean best spectacle-corrected visual acuity was 0.13 ± 0.14 logMAR in DSEK and 0.01 ± 0.18 logMAR in DMEK grafts ( P <0.00001) at 5 years postoperatively. Rebubbling was performed in 7.8% DSEK and 2.1% DMEK grafts ( P = 0.441). Cox regression identified rejection episodes (HR 6.5; 95% CI: 1.70-24.8; P = 0.0062) as a significant contributing factor for graft failure. CONCLUSIONS: DMEK had superior visual acuity outcomes compared with DSEK in these patients up to 5 years after surgery. At 5 years, there was no significant difference in graft survival or endothelial cell loss between DSEK and DMEK eyes with FED. We propose that our standardized technique reduces the need for rebubbling.

Tectonic mini-Descemet stripping endothelial keratoplasty (mini-DSEK) in the management of corneal perforation secondary to pediatric blepharokerato conjunctivitis.

Blepharokeratoconjunctivitis (BKC) in children can have a broad clinical spectrum. Corneal involvement, including perforation, can occur in severe cases. Management aims to restore anatomical integrity and preserve visual function. We report the outcome of a novel technique, tectonic mini-Descemet stripping endothelial keratoplasty (mini-DSEK), to treat a corneal perforation secondary to BKC in a 14-year-old boy after failure to respond to cyanoacrylate glue application and multilayer amniotic membrane patch grafting. On follow-up 8 months postoperatively, the perforation remained sealed, and visual acuity was preserved. The major advantages of this technique are the avoidance of suture-related complications, reduced risk of immunological rejection, minimized postoperative refractive error, and rapid visual rehabilitation.

Rebubbling and graft detachment in Descemet membrane endothelial keratoplasty using a standardised protocol.

OBJECTIVES: To analyse risk factors and long-term outcomes after rebubbling and graft detachment in Descemet membrane endothelial keratoplasty (DMEK). METHODS: 176 consecutive DMEK grafts of 125 patients performed by 8 surgeons with a standardised technique between January 2015 and July 2022 were analysed. Main outcome measures were graft detachments, rebubbling rate, postoperative outcomes, and risk factors for graft failure and rebubbling. RESULTS: 6 (3.4%) grafts required rebubbling (>1/3 area detached). 40 (22.7%) grafts developed self-resolving partial detachments (<1/3 area detached). The mean time to rebubble was 16 ± 9.4 days. Mean BSCVAs at 5 years postoperative were 0.03 ± 0.16, 0.03 ± 0.14, and 0.15 ± 0.31 logMAR in fully attached, partially detached and rebubbled grafts (P = 0.437). 5-year graft survival were 98%, 90%, and 83% in fully attached, partially detached and rebubbled eyes (P = 0.02). There was significantly greater endothelial cell loss (ECL) in the rebubbled eyes (P = 0.018). Intraoperative trauma was a risk factor for graft failure (HR 1.81; 95% CI: 1.33-2.50; P = 0.023). An indication for surgery other than Fuchs endothelial dystrophy was a risk factor for rebubbling (HR 5.28; 95% CI: 5.11-72.4; P = 0.007). CONCLUSION: DMEK grafts had better graft survival if there was no partial detachment or rebubbling at 5 years postop. There was significant ECL associated with rebubbling. A standardised technique reduces rebubbling and graft failure risk.

Giant Cell Arteritis Presenting as Bilateral Cotton Wool Spots.

An 81-year-old Afro-Caribbean woman presented with a two-week history of a dull headache in her temples, jaw claudication especially when chewing food, and reduced vision in her eyes, more pronounced in the right eye. There was no past medical or family history of hypothyroidism or autoimmunity. On examination, the vision was counting fingers in the right eye and 6/36 in the left eye, best corrected. Dilated fundus examination revealed multiple peripapillary cotton wool spots in both eyes though more pronounced in the right. Her erythrocyte sedimentation rate (ESR) was 120 mm/h, and her C-reactive protein (CRP) level was 79 mg/L. A temporal artery ultrasound scan was undertaken immediately which demonstrated a halo sign around both temporal arteries and so a giant cell arteritis (GCA) diagnosis was made. The patient was commenced on daily high-dose IV methylprednisolone 1 g for three days and referred to the rheumatology team. Her vision improved to 1/60 right and 6/9 left eye best corrected at three days post-treatment. At 12 months after the initial presentation, her vision stabilized at 6/60 in the right and 6/6 with complete visual fields in the left eye. Cotton wool spots can be a sign of GCA. Their appearance with or without characteristic systemic symptoms should prompt urgent evaluation.

Long-term Outcomes of Descemet Stripping Endothelial Keratoplasty: Ten-Year Graft Survival and Endothelial Cell Loss.

PURPOSE: To determine 10-year outcomes for graft and endothelial cell survival after Descemet stripping endothelial keratoplasty (DSEK), including risk factors for graft failure. DESIGN: Retrospective clinical cohort study. METHODS: Three hundred fifty-six consecutive DSEK grafts performed by 10 surgeons using a standardized protocol were analyzed. Primary outcomes were cumulative graft survival and percentage endothelial cell loss (ECL) from 6 months to 10 years; secondary outcomes included risk factors for graft failure, postoperative complications, visual outcomes, and central corneal thickness. RESULTS: Indications include Fuchs endothelial dystrophy (n = 209), bullous keratopathy (n = 88), and previous graft failure (n = 39). One hundred and four eyes (29%) had preoperative glaucoma. Cumulative graft survival rates of all eyes at 1, 3, 5, and 10 years were 97%, 90%, 85%, and 79%, respectively. Ten-year graft survival for Fuchs endothelial dystrophy was 92%. Mean ± SD percentage ECL of all grafts was 46.6% ± 17.3% at year 1, 54.9% ± 18.7% at year 3, 59.6% ± 17.4% at year 5, and 73.1% ± 9.7% at year 10. Cox regression identified preoperative glaucoma (hazard ratio [HR]: 8.41; 95% CI, 1.30-54.5; P = .026), including previous glaucoma surgery (HR: 3.63; 95% CI: 1.03-12.74; P = .04) and regrafts (HR: 5.29; 95% CI: 2.02-13.89; P = .001) as significant risk factors for graft failure. CONCLUSIONS: At 10 years, DSEK survival rate was 79% for all eyes, including complex grafts, and ECL was 73%. For Fuchs endothelial dystrophy, 10-year graft survival rate was 92%. Despite a mean 10-year endothelial cell count of only 692 cells/mm2, graft survival remained high with good vision. DSEK continues to be a viable treatment option, especially in complex eyes with comorbidity.

Subconjunctival Ab Externo Gel Stent Implantation for Refractory Glaucoma After High-Risk Penetrating Keratoplasty.

This case study reports the successful deployment of the XEN45 gel stent (AbbVie Inc, Chicago, IL) through an ab externo approach in a 73-year-old woman with refractory glaucoma following high-risk penetrating keratoplasty (PK) 10 years prior. The PK was for corneal perforation secondary to peripheral ulcerative keratitis, which required systemic immunosuppression comprising intravenous cyclophosphamide, azathioprine, and corticosteroids to stabilise the disease and prevent corneal graft rejection. The patient's intraocular pressure was reduced from 40 mmHg preoperatively to 12 mmHg six months after surgery, off medication. The patient's visual acuity and visual fields remained stable. The XEN45 gel stent utilising the ab externo approach can be considered as a potential tool to lower intraocular pressure in patients with glaucoma after corneal keratoplasty.

The Influence of Optical Coherence Tomography Measurements of Retinal Nerve Fiber Layer on Decision-Making in Glaucoma Diagnosis.

PURPOSE: To quantify the influence of spectral domain optical coherence tomography (SDOCT) on decision-making in patients with suspected glaucoma. METHODS: A prospective cross-sectional study involving 40 eyes of 20 patients referred by community optometrists due to suspected glaucoma. All patients had disc photographs and standard automated perimetry (SAP), and results were presented to 13 ophthalmologists who estimated pre-test probability of glaucoma (0-100%) for a total of 520 observations. Ophthalmologists were then permitted to modify probabilities of disease based on SDOCT retinal nerve fiber layer (RNFL) measurements (post-test probability). The effect of information from SDOCT on decision to treat, monitor, or discharge was assessed. Agreement among graders was assessed using intraclass correlation coefficients (ICC) and correlated component regression (CCR) was used to identify variables influencing management decisions. RESULTS: Patients had an average age of 69.0 ± 10.1 years, SAP mean deviation of 2.71 ± 3.13 dB, and RNFL thickness of 86.2 ± 16.7 µm. Average pre-test probability of glaucoma was 37.0 ± 33.6% with SDOCT resulting in a 13.3 ± 18.1% change in estimated probability. Incorporating information from SDOCT improved agreement regarding probability of glaucoma (ICC = 0.50 (95% CI 0.38 to 0.64) without SDOCT versus 0.64 (95% CI 0.52 to 0.76) with SDOCT). SDOCT led to a change from decision to "treat or monitor" to "discharge" in 22 of 520 cases and a change from "discharge" to "treat or monitor" in 11 of 520 cases. Pre-test probability and RNFL thickness were predictors of post-test probability of glaucoma, contributing 69 and 31% of the variance in post-test probability, respectively. CONCLUSIONS: Information from SDOCT altered estimated probability of glaucoma and improved agreement among clinicians in those suspected of having the disease.

Visual improvement following glaucoma surgery: a case report.

BACKGROUND: Glaucoma is a progressive optic neuropathy and a leading cause of blindness. Neural losses from glaucoma are irreversible, and so the aim of glaucoma treatment is to slow progression and minimize the risk of further damage. Functional improvement with treatment is not expected. We report the case of a patient who experienced a significant improvement in vision following glaucoma surgery and review the literature regarding this phenomenon. CASE PRESENTATION: A 64-year old male presented with a 13-month history of gradual vision loss in the right eye to the extent that he could only perceive hand movements. His intraocular pressure (IOP) measured 50 mmHg and he was found to have advanced primary open angle glaucoma. Medical treatment was commenced and he underwent a successful right Mitomycin C-augmented trabeculectomy. Unexpectedly he experienced marked improvement in vision post-operatively, with improvements maintained through six months of follow-up. At his most recent visit visual acuity was 6/18 in the affected eye. Although the mechanism of improved vision cannot be proven it is likely that successful lowering of IOP resulted in some reversal of retinal ganglion cell dysfunction. Important factors may have included his relatively young age, high IOP and short duration of symptoms. CONCLUSION: Although rare, functional improvements may occur following trabeculectomy. Glaucoma surgery should be offered early to those with advanced disease, and considered even in those with reduced visual acuity.