1 year posterior corneal changes after Bowman Layer Transplant for keratoconus.

INTRODUCTION: To report the posterior corneal changes after Bowman Layer Transplant for keratoconus in a tertiary hospital in the UK. METHODS: 5 eyes of 5 patients receiving Bowman Layer Transplant for advanced keratoconus in Royal Gwent Hospital (Newport, UK) were included. Pre and postoperative posterior corneal astigmatism, posterior Kmean, and back surface elevation were analysed. RESULTS: No significant changes were seen in the posterior corneal astigmatism, posterior Kmean, or back surface elevation between the pre- and postoperative period. CONCLUSION: This results would support the idea that the corneal changes seen after Bowman Layer Transplant are mainly in the anterior corneal surface.

Dupilumab-associated ocular surface disease: presentation, management and long-term sequelae.

OBJECTIVES: To determine the presenting features of ocular surface disease in patients with atopic dermatitis (AD) treated with dupilumab at a tertiary, university hospital. To establish the need for treatment of dupilumab-associated ocular surface disease and report any long-term effects on the ocular surface. METHODS: A retrospective analysis of consecutive patients treated with dupilumab for AD between January 2017 and August 2019 was undertaken. Data were collected on demographics, incidence and type of ocular disease features, natural history and treatment. RESULTS: A total of 50% (14/28) patients developed ocular symptoms with a mean time of onset of 6.75 (±6.1) weeks from starting dupilumab. Of these, 69% (9/13) were diagnosed with conjunctivitis associated with cicatrisation in two patients and periorbital skin changes in four. Of these nine, four had prior history of atopic keratoconjunctivitis. All were treated with topical steroids; two required additional ciclosporin drops. In all, 67% (6/9) patients went on to have on-going ocular inflammation requiring maintenance drops at a mean of 16 (±6.9) months of follow-up. All patients had improvement in their AD severity; only one patient discontinued dupilumab due to ocular side effects. CONCLUSION: The rate of dupilumab-associated ocular surface disease was 32%. Periorbital skin changes and conjunctival cicatrisation were noted in association with conjunctivitis. Ocular surface disease improved on topical steroids and ciclosporin but 67% of patients needed on-going treatment. Close liaison with an ophthalmologist should be considered in those patients who develop conjunctivitis or have a past history of severe ocular surface disease.

Tectonic Descemet Stripping Endothelial Keratoplasty for the Management of Corneal Perforation: A Case Series.

PURPOSE: Corneal perforations pose a considerable challenge for ophthalmic surgeons. The aim remains restoring the anatomical integrity of eye while attempting to preserve as much visual function as possible. To our knowledge, we report the first case series of 4 successful tectonic Descemet stripping endothelial keratoplasty (DSEK) grafts completed for acute corneal perforation. In all cases, restoration of globe integrity was achieved. In cases where visual potential remained, deep anterior lamellar keratoplasty over DSEK was offered. METHODS: Four patients presenting to Royal Gwent Hospital (Newport, Wales) with corneal perforation were included. Etiological origins included exposure keratopathy, corneal hydrops secondary to pellucid marginal degeneration with fistulization-associated aqueous leak, and herpetic keratitis. Patients were treated with initial temporary therapies, including glue patch, the use of bandage contact lenses, amniotic membrane transplant, and antibiotic cover, depending on the size and location of the perforation. Subsequent DSEK was subsequently performed under local anesthesia. RESULTS: All patients had successful tectonic grafts (3 DSEKs and 1 hemi-DSEK) up to 4 months postoperatively. In the case involving a hemi-DSEK, the patient underwent 2 refloating attempts of the graft before anchoring suture placement because of repeated graft detachment. Successful graft placement and tectonic globe restoration was confirmed by anterior segment imaging. CONCLUSIONS: Tectonic DSEK provides corneal surgeons with a new modality of treating corneal perforations. It provides clinicians an additional tool in their armamentarium in complex cases where anterior lamellar or penetrating keratoplasty may be contraindicated or deemed high risk of complications.

Modified thin manual Descemet stripping endothelial keratoplasty with air-guided, non-pachymetric donor lenticule dissection: outcomes of graft thickness and complication rate.

AIM: To describe a modified technique of donor lenticule dissection for thin manual Descemet stripping endothelial keratoplasty (TM-DSEK). METHODS: Donor material was soaked in balanced salt solution (BSS) for 30min, before being mounted on an artificial anterior chamber (AAC). Rather than BSS, the AAC was filled with filtered air, resulting in a visible reflection at the corneal endothelium-air interface. This reflection served as a landmark for the depth of the dissection, facilitating the creation of a thin lenticule with low risk of perforation. Dissection was commenced at a standardized depth of 500 microns, with no initial pachymetry necessary. Totally 29 donor corneas were dissected by a novice TM-DSEK surgeon. Dissection time, central graft thickness at 2mo and complications were analysed. RESULTS: Results were similar to other endothelial keratoplasty techniques, despite the cases being performed by a novice DSEK surgeon. Mean dissection time was 7min (range 6-10). One graft perforation occurred (3.45%), but the air tamponaded the break and enabled dissection to be restarted and completed from a different location. Mean central graft thickness after at least two months follow-up was 106 microns (range 25-170). CONCLUSION: A problem with manual DSEK is the risk of graft perforation by attempting to dissect too thin a lenticule, or creating a thick graft due to fear of perforating. This modified air-guided technique addresses this problem, and is recommended for surgeons either embarking on the learning curve, or who wish to achieve more consistently thin grafts while reducing perforation rates.

Neurotrophic keratopathy.

Neurotrophic Keratopathy (NK) refers to a condition where corneal epitheliopathy leading to frank epithelial defect with or without stromal ulceration (melting) is associated with reduced or absent corneal sensations. Sensory nerves serve nociceptor and trophic functions, which can be affected independently or simultaneously. Loss of trophic function and consequent epithelial breakdown exposes the stroma making it susceptible to enzymatic degradation. Nerve pathology can range from attrition to aberrant re-generation with corresponding symptoms from anaesthesia to hyperaesthesia/allodynia. Many systemic and ocular conditions, including surgery and preserved medications can lead to NK. NK can be mild (epithelium and tear film changes), moderate (non-healing epithelial defect) or severe (stromal melting and perforation). Moderate and severe NK can profoundly affect vision and adversely impact on the quality of life. Medical management with lubricating agents from artificial tears to serum/plasma drops, anti-inflammatory agents, antibiotics and anti-proteases all provide non-specific relief, which may be temporary. Contact lenses, punctal plugs, lid closure with botulinum toxin and surgical interventions like tarsorrhaphy, conjunctival flaps and amniotic membrane provide greater success but often at the cost of obscuring sight. Corneal surgery in a dry ocular surface with reduced sensation is at high risk of failure. The recent advent of biologicals such as biopolymers mimicking heparan sulfate; coenzyme Q10 and antisense oligonucleotide that suppress connexin 43 expression, all offer promise. Recombinant nerve growth factor (cenegermin), recently approved for human use targets the nerve pathology and has the potential of addressing the underlying deficit and becoming a specific therapy for NK.

Determinants of visual quality after endothelial keratoplasty.

Endothelial keratoplasty is now favored over full-thickness penetrating keratoplasty for corneal decompensation secondary to endothelial dysfunction. Although endothelial keratoplasty has evolved as surgeons strive to improve outcomes, fewer patients than expected achieve best corrected visual acuity of 20/20 despite healthy grafts and no ocular comorbidities. Reasons for this remain unclear, with theories including anterior stromal changes, differences in graft thickness and regularity, induced high-order aberrations, and the nature of the graft-host interface. Newer iterations of endothelial keratoplasty such as thin manual Descemet stripping endothelial keratoplasty, ultrathin automated Descemet stripping endothelial keratoplasty, and Descemet membrane endothelial keratoplasty have achieved rates of 20/20 acuity of approximately 50%, comparable to modern cataract surgery, and it may be that a ceiling exists, particularly in the older age group of patients. Establishing the relative contribution of the factors that determine visual quality following endothelial keratoplasty will help drive further innovation, optimizing visual and patient-reported outcomes while improving surgical efficacy and safety.