Twenty years of limbal epithelial therapy: an update on managing limbal stem cell deficiency.

Limbal stem cell damage after chemical injury, autoimmune disorders or iatrogenic trauma leads to corneal conjunctivalisation with new vessel formation, epithelium instability and visual loss. Limbal stem cell transplantation includes reconstructive surgical procedures to restore a corneal epithelium. The recognised options are: conjunctival limbal autograft, in which stem cells are taken from the patient's healthy eye; conjunctival limbal allograft, in which stem cells are taken from a living, related or dead donor and the keratolimbal allograft. Each of these procedures has some drawbacks; in particular, the conjunctival limbal autograft needs a relatively healthy fellow eye and needs a relatively large amount of donor tissue from the healthy eye (about one-third of the healthy limbal stem cell tissue) with potential risks to the donor eye. In the case of keratolimbal allograft transplants, the recipient needs an immunosuppressive treatment to reduce the risk of rejection with the associate possible side effects. More modern treatment options are reviewed. Cultivated oral mucosa epithelial transplantation success rate can vary between 50% and 70% at 3-4 years of follow-up. Simple limbal epithelial transplantation results show a success rate from 75.2% to 83.8% after 1 year of follow-up. Inclusion criteria for autologous cultivated limbal epithelial transplantation as approved by the National Institute of Health and Care Excellence are also shown in this paper. On the basis of these more contemporary treatment options, a stepladder approach to evaluate which procedure is most appropriate and personalised to the patient's conditions is proposed.

Functional and aesthetic outcomes of eyelid skin grafting in facial nerve palsy.

AIM: To report the functional and aesthetic outcomes of eyelid full-thickness skin grafting (FTSG) in patients with facial nerve palsy (FNP). METHODS: This is a retrospective, non-comparative, single-centre review of all patients with FNP who underwent FTSG over an 8-year period. Functional outcomes were collected through case notes review: CADS (cornea, static asymmetry and dynamic and synkinesis) score facial nerve grading and lagophthalmos on blink, gentle and forced closure. Marginal reflex distance (MRD1 and MRD2) was calculated on standardised photographs. The aesthetic outcomes were assessed objectively by two blinded independent assessors who assessed standardised photographs based on a mutually agreed grading scale. Both functional and aesthetic outcomes were measured preoperatively, and at early (1-3 months), intermediate (3-6 months) and late (>9 months) postoperative periods. RESULTS: A total of 28 eyelid FTSGs were performed on 21 patients (11 female, 10 male) between 2008 and 2016. The mean age was 68 (range, 16-89) years and the mean follow-up was 20.8 (range, 12-30) months. The CADS score (cornea (p<0.001), static asymmetry (p<0.001), dynamic function (p<0.001)), MRD2 (p=0.002) and lagophthalmos (blink (p=0.003), gentle (p<0.001), forced (p=0.003)) improved through early and late postoperative periods. Aesthetically, the grafts appeared to look natural in terms of colour, surface contour and graft edge from the intermediate postoperative period and continued to improve significantly by the late postoperative period. CONCLUSION: The use of periocular FTSG is effective in improving lagophthalmos and periorbital symmetry in patients with FNP where skin contraction exists. They should be considered as an adjunct to other oculoplastic procedures for both functional and aesthetic rehabilitation.

Rectus Muscle Resection for Vertical Strabismus in Thyroid Eye Disease.

PURPOSE: Rectus muscle resection in thyroid eye disease (TED) is generally avoided due to the risk of worsening restriction or reactivating inflammation. However, for some patients with large-angle strabismus or diplopia in primary gaze despite maximum recession surgery, rectus muscle resection may be beneficial. We report our surgical experience with rectus muscle resection in the management of vertical strabismus associated with TED. METHODS: Retrospective review of eight patients with TED and vertical diplopia who underwent vertical rectus muscle resection by a single surgeon (IBM) at a tertiary referral centre in Liverpool, UK, from 2001 to 2013. The goal of surgery was elimination of diplopia in primary and reading position. Vertical deviations were measured in prism dioptres (∆) before and after surgery at one month, four months and final visit by prism alternate cover testing at ⅓ m and 6 m. RESULTS: The mean ± standard deviation vertical deviation for near and distance reduced significantly from 14.2∆ ± 8.4∆ and 15.8∆ ± 8.8∆ pre-operatively to 5.7∆ ± 4.9∆ and 6.7∆ ± 7∆ at the four-month visit, respectively (p< 0.05). At the four-month follow-up, five (62.5%) patients achieved binocular single vision in primary and reading position with either no prisms or prisms less than 5∆. Further recession surgery, Harada-Ito procedure, or lateral rectus resection were necessary in four (50%) patients with persistent diplopia. No patient developed recurrence of inflammation or increased muscle restriction. CONCLUSIONS: Vertical rectus resection could be considered as an additional surgical strategy in the management of TED patients with vertical strabismus without adverse sequelae.

Oral mucosa grafting in periorbital reconstruction.

To provide an extensive literature review on the clinical indications of oral mucosa grafts (OMG) and minor salivary gland grafts (MSGG) in periorbital reconstruction together with safe practice graft harvesting techniques to minimize donor-site morbidity. A literature review was performed by searching the databases of PUBMED, EMBASE, and COCHRANE library using the keywords: minor salivary glands; oral mucosal graft; orbit; and eye. The bibliographies of the pertinent articles were examined for additional papers. Indications for OMG include treatment of recurrent pterygia; socket contracture in anophthalmic patients; repair of eyelid deformities; ocular surface and fornix reconstruction following tumour resection, cicatricial ocular surface disorders, or chemical burns. More novel uses include repair of glaucoma aqueous drainage device erosions or leaking trabeculectomy blebs; scleral buckle exposure; and keratoprosthesis-related corneal melts as well as lining the dacryocystorhinostomy tract to prevent closure. Simultaneous MSGG transplantation may be used in the treatment of severe dry eyes or dry anophthalmic cavities. Harvesting from the inner cheek is preferred to lower lip as it causes less post-operative discomfort and neurosensory deficits. Suturing is recommended for smaller ovoid grafts as it allows less painful closure without tension, while larger rectangular defects are best left to heal by secondary intention. OMG and MSGG transplantation is a viable alternative to replace conjunctiva and restore the ocular surface. The donor site is readily accessible and widely available in most patients, grafting is fast and cheap, and the same site may undergo repeated harvesting with few donor site complications.

Multifocal choroiditis with panuveitis in an 8-year-old boy with long-standing idiopathic acute anterior uveitis.

PURPOSE: To report successful treatment of a rare case of sight-threatening pediatric multifocal choroiditis with panuveitis (MFCPU) and the use of electrophysiology to confirm return of macular function. METHODS: Case report. RESULTS: An 8-year-old boy with a history of bilateral recurrent non-juvenile idiopathic arthritis acute anterior uveitis (AAU) presented with new-onset blurry vision and floaters in both eyes. Visual acuity had deteriorated to 20/200 right eye and 20/100 left eye. Cells were observed in the anterior chamber and vitreous of both eyes. Ophthalmoscopy showed multiple active small cream-colored chorioretinal lesions and cystoid macular edema (CME) in both eyes in the absence of systemic disease, suggestive of idiopathic MFCPU. Successful rapid visual recovery and resolution of CME confirmed by spectral-domain optical coherence tomography (SD-OCT) was achieved with prompt intensive systemic steroid therapy followed by early introduction of methotrexate. After 9 months, his visual acuities improved to 20/32, and pattern reversal visual evoked potentials and 19 hexagon multifocal electroretinography posttreatment were normal, showing recovery of macular function. CONCLUSIONS: Multifocal choroiditis with panuveitis is rare in children and has not been documented in the presence of previous longstanding recurrent AAU. Onset of floaters in children should alert the clinician to early stages of posterior pole involvement and progression to reduction in vision due to CME requires prompt aggressive steroid therapy monitored by clinical examination, SD-OCT, and electrophysiology, followed by early introduction of immunosuppressive drugs for long-term stability and to avoid steroid-induced adverse effects in children.

Bilateral optic disc edema as a presentation of an obstructing spinal plasmacytoma.

PURPOSE: To report a rare case of bilateral optic disc edema as presentation of an obstructing spinal plasmacytoma. METHODS: Case report. RESULTS: A 41-year-old healthy man presented with distortion of his peripheral vision for 9 months. He denied headaches or neurologic symptoms. Examination showed bilateral optic disc swelling, radial disc hemorrhages, and absent spontaneous venous pulsations. Brain magnetic resonance imaging (MRI) and magnetic resonance venography were unrevealing. Lumbar puncture showed a normal opening pressure of 19 cm cerebrospinal fluid (CSF). CSF protein was significantly elevated at 3.22 g/L (0.10-0.45 g/L). Spinal MRI with contrast revealed a tumor in the T9 vertebral body extending through the disc spaces into T8 and T10, compressing the spinal cord. Computed tomography-guided biopsy confirmed a spinal plasmacytoma. He received radiotherapy to the spine T7-T11 to reduce spinal cord compression followed by a 6-month course of chemotherapy with dexamethasone, cyclophosphamide, and thalidomide. Disc swelling improved on starting radiotherapy with complete resolution 8 months posttreatment. MRI spine showed reduction of tumor. CONCLUSIONS: This case highlights the importance of spinal imaging in patients with normal cranial scans and raised CSF protein levels who lack the typical idiopathic intracranial hypertension phenotype.

Vitreoretinal surgery for complications of choroidal tumor biopsy.

OBJECTIVE: To determine the outcomes of vitreoretinal surgery after choroidal tumor biopsy. DESIGN: Retrospective, single-center, consecutive case series. PARTICIPANTS: A total of 739 consecutive patients undergoing choroidal tumor biopsy. METHODS: All subjects who underwent transretinal or transscleral choroidal tumor biopsy for diagnostic or prognostic purposes between May 1993 and May 2013 were identified in our database. We then reviewed patients who subsequently required secondary vitreoretinal surgery for complications arising from such biopsies. MAIN OUTCOME MEASURES: Reason for vitreoretinal surgery, association with biopsy procedure, best-corrected visual acuity (BCVA; logarithm of the minimum angle of resolution [logMAR]), intraocular or extrascleral tumor dissemination, resolution of vitreous hemorrhage, reattachment of the retina with a single vitreoretinal procedure, number of additional vitrectomies undertaken, and number of enucleations. RESULTS: A total of 20 of 739 eyes (2.7%) underwent vitreoretinal surgery for complications arising from choroidal tumor biopsy. The tumors consisted of choroidal melanoma in all 20 eyes. The reasons for the secondary surgery included persistent vitreous hemorrhage in 1.9% (14/739), rhegmatogenous retinal detachment in 0.7% (5/739), and endophthalmitis in 0.14% (1/739). Median BCVA improved from 2.0 logMAR (mean, 1.92 logMAR; range, 0.8-2.7 logMAR) before vitrectomy to 0.72 logMAR (mean, 0.88 logMAR; range, -0.14 to 2.7 logMAR) after vitrectomy and 0.76 logMAR (mean, 1.14 logMAR; range, 0.1-3.0 logMAR) at the final visit (P < 0.0001, t test). Permanent resolution of vitreous hemorrhage was achieved in 6 of 14 patients, and reattachment of the retina was achieved in 2 of 5 patients after the first vitrectomy. A median of 1 (mean, 1.5; range, 1-3) additional vitrectomy was performed. Enucleation was necessary in 3 of 20 eyes (15%). There were no cases of intraocular invasion or extrascleral extension after vitrectomy. CONCLUSIONS: Vitrectomy for complications of choroidal tumor biopsy is rare. Such corrective surgery is complex and is best undertaken by specialized ocular oncologists or vitreoretinal surgeons with experience in managing this problem.

Phacoemulsification surgery in eyes with neovascular age-related macular degeneration.

Purpose. To evaluate the visual outcomes and effect of phacoemulsification surgery on the progression of neovascular age-related macular degeneration (AMD). Methods. Retrospective, noncomparative, and interventional case series. Thirty eyes from 29 subjects with neovascular AMD treated with intravitreal antivascular endothelial growth factor (VEGF) injections who underwent phacoemulsification and had a postsurgery follow-up of 6 months were included. LogMAR best corrected visual acuity (BCVA) was assessed preoperatively; 1 month, 3 months, and 6 months postoperatively; and finally at the last visit. The frequency of anti-VEGF therapy, calculated as the number of intravitreal injections per month, and central macular thickness (CMT) before and after cataract surgery were determined. Results. Median (range) logMAR BCVA was 0.69 (0.16 to 1.32) preoperatively; 0.55 (-0.04 to 1.32) at 1 month, 0.52 (-0.1 to 1.32) at 3 months, and 0.50 (0.0 to 1.32) at 6 months postoperatively; and 0.6 (0.0 to 1.4) at final visit (P = 0.0011). There was no difference in the frequency of anti-VEGF injections between the immediate 6 months before and after phacoemulsification, which was equal to 0.1667 injections per month (P = 0.6377). Median CMT measured 203 µ m preoperatively, which temporarily increased to 238 µ m at 1 month after surgery (P = 0.0093) and then spontaneously returned to baseline, measuring 212.5 µ m at 3 months postoperatively (P = 0.3811). Conclusion. Phacoemulsification surgery significantly improved vision in patients with neovascular AMD, with no increased need for anti-VEGF injections to keep the macula dry postoperatively.

An effective programme to systematic diabetic retinopathy screening in order to reduce diabetic retinopathy blindness.

The number of people identified with diabetes in England increased by nearly 5% during 2011-2012 to well over 2.5 million. During 2011-2012 the NHS Diabetic Eye Screening Programme screened more than 1.9 million people. In general, the UK is doing very well with its DR screening targets. It is a world leader in diabetic retinopathy screening, having offered 85.7% of eligible diabetic patients the screening programme. However, the target is 100% and efforts are still being made to improve screening locally. Our aim is to evaluate the prevalence of sight-threatening diabetic retinopathy (STDR) (proliferative retinopathy or maculopathy), the number of patients needing laser treatment or vitrectomy and registered blind in the last 12 months in a defined population. We did a twelve-month retrospective database review at the Systematic Diabetic Retinopathy Screening Service at Wirral University Hospital Trust, United Kingdom. The effectiveness of different screening modalities has been widely investigated. UK studies show sensitivity levels for the detection of sight-threatening diabetic retinopathy of 41%-67% for general practitioners, 48%-82% for optometrists, 65% for ophthalmologists, and 27%-67% for diabetologists and hospital physicians using direct ophthalmoscopy. Sensitivity for the detection of referable retinopathy by optometrists have been found to be 77%-100%, with specificity of 94%-100%. Photographic methods currently use digital images with subsequent grading by trained individuals. Sensitivity for the detection of sight-threatening diabetic retinopathy have been found 87%-100% for a variety of trained personnel reading mydriatic 45° retinal photographs, with specificities of 83%-96%. The British Diabetic Association (Diabetes UK) has established standard values for any diabetic retinopathy screening programme of at least 80% sensitivity and 95% specificity. We used descriptive analyses to characterise the study population and patterns of diabetic retinopathy, and used t tests and χ(2) tests to explore differences between patients without any retinopathy and those who developed any, background, or referable retinopathy. Parametric survival analysis with covariates identified those factors associated with the development of referable retinopathy. The presence of diabetic retinopathy was determined after each screening event during the study period. Although intended to occur annually, screening took place at variable times during the one year period. Of known diabetics in a total population 325.000, 84% accessed screening and 15.196 (4.7%) were screened. 748 were referred with referable retinopathy. 16% of the patients needed laser treatment for the first time, 30 patients needed vitrectomy, and 16 were registered blind. To evaluate the effectiveness of diabetic retinopathy screening (DRS) service we did a retrospective comparative analysis of 2 year DRS data in Wirral (2010-2012). An increase of 6.8% in the number of diabetics was noted over the last 12 months compared to the previous period. Referable retinopathy decreased from 5.6% for 2010-2011 to 4.94% during the same period in 2011-2012. In particular, the incidence of proliferative retinopathy (R3) has dropped from 0.7% last year to 0.52% this year. STDR has significant impact on ophthalmic services, but a well-implemented program provides timely treatment, reducing the need for vitrectomy and blind registration and serving as a benchmark to plan service delivery in a similar population.

Steroid induced central serous chorioretinopathy in giant cell arteritis.

Giant cell arteritis (GCA) is an ophthalmic emergency which requires early diagnosis and treatment with high dose systemic corticosteroids in order to prevent permanent visual loss. However, systemic corticosteroids have significant ocular side effects including cataract formation, raised intraocular pressure, and less commonly, central serous chorioretinopathy (CSCR). We report a case of visual loss secondary to CSCR complicating corticosteroid therapy in GCA. When assessing patients with systemic conditions such as GCA or other vasculitic process, who complain of visual loss which is getting worse on corticosteroid treatment, clinicians should consider other causes such as CSCR as part of the differential diagnosis. Extra caution should be exercised in such cases as increasing the dose of corticosteroids might aggravate CSCR resulting in further visual loss.

Corneal protection during general anesthesia for nonocular surgery.

Corneal abrasion is the most common ophthalmologic complication that occurs during general anesthesia for nonocular surgery. Such abrasions can be caused by a variety of mechanisms and can lead to sight-threatening microbial keratitis and permanent scarring. There is no standard mode of protecting the cornea during general anesthesia for nonocular surgery. Methods described in the literature are not entirely effective and may be associated with unwanted side effects. Taping alone provides protection that is equivalent or superior to other interventions and has fewer side effects. Petroleum gel is flammable and is best avoided when electrocautery and open oxygen are to be used around the face. Preservative-free eye ointment is preferred, as preservative can cause corneal epithelial sloughing and conjunctival hyperemia. Recently, the application of Geliperm and bio-occlusive dressings has been advocated. Geliperm may be particularly useful during endonasal surgery when continuous perioperative observation of the eye is required. In this article, the literature on the etiology of perioperative corneal abrasions is reviewed and various protection strategies are compared in order to identify the best methods to prevent corneal abrasions during general anesthesia.

Uncommon ophthalmologic disorders in intensive care unit patients.

Ophthalmologic complications are frequently encountered in intensive care unit (ICU) patients (Grixti et al. Ocul Surf 2012;10(1):26-42). However, eye care is often overlooked in the critical care setting or just limited to the ocular surface because treatment is focussed on the management of organ failures. Lack of awareness about other less common intraocular sight-threatening conditions may have a devastating effect on the patient's vision. To identify specific, frequently missed uncommon ocular disorders in ICU, a literature review using the keywords "Intensive Care," "Eye care," "ITU," "ICU," "Ophthalmological disorders," "Eye disorders" was performed. The databases of CINAHL, PuBMed, EMBASE, and Cochrane library were searched. The higher quality studies are summarized in the table with statements of methodology to clarify the level of evidence. The most prevalent ophthalmologic disorders identified in critically ill subjects include exposure keratopathy, chemosis, and microbial keratitis. In addition, uncommon eye disorders reported in ICU include metastatic endogenous endophthalmitis, acute primary angle closure, ischemic optic neuropathy, pupil abnormalities, vascular occlusions, and rhino-orbital cerebral mucormycosis. Early diagnosis and effective treatment will help to prevent visual loss.

Common ocular surface disorders in patients in intensive care units.

Ocular surface disorders are frequently encountered in patients in Intensive Care Units (ICUs). Because of significant impairment of major organs, treatment is focused on the management of organ failures. Therefore, ophthalmological complications are frequently overlooked in this setting. To identify the types and frequencies of ocular surface disorders reported in patients in ICUs, a literature review using the keywords: Intensive Care; Eye care; ICU; ITU; Ophthalmological disorders; Eye disorders was performed. The databases of CINAHL, PUBMED, EMBASE and COCHRANE library were searched. The higher quality papers are summarized in tables with statements of methodology to clarify the level of evidence. The most prevalent ocular disorders identified in ICU patients were exposure keratopathy (3.6% to 60%), chemosis (9% to 80%), and microbial keratitis. Of the various eye care measures that have been advocated to prevent exposure keratopathy, the most effective is the application of moisture chambers or polyethylene covers. Early diagnosis and effective treatment will help to prevent microbial keratitis and visual loss.