Effect of donor graft quality on clinical outcomes after deep anterior lamellar keratoplasty.

PURPOSE: The aim of this study was to determine the effect of donor features, including age, death-to-preservation time, preservation-to-surgery time, graft rating, and endothelial cell features, on visual and refractive outcomes and complications occurring after deep anterior lamellar keratoplasty (DALK) in patients with keratoconus. METHODS: In this retrospective study, 290 consecutive keratoconic eyes underwent DALK using donor corneas of different qualities, ranging from fair to excellent. Donor corneas were stored in intermediate-term storage medium. Donor data included age and sex, death-to-preservation time, preservation-to-surgery time, epithelial and stromal status, endothelial cell density and morphology, and graft rating. Postoperative outcomes included visual acuity, refractive error, epithelial problems, suture-related complications, graft rejection, and graft transparency. A multivariate regression analysis was used to assess the correlation between donor characteristics and postoperative outcomes. RESULTS: Mean donor and recipient ages were 33.4 ± 13.1 and 27.7 ± 8.0 years, respectively. The mean follow-up period was 38.2 ± 20.2 months. The presence of epithelial defects on postoperative day 1 had a significant correlation with donor epithelial sloughing (R = 0.26, P < 0.001), preservation-to-surgery time (R = 0.21, P = 0.001), and graft rating (R = -0.17, P = 0.004). Graft stromal edema on postoperative day 1 was significantly correlated with donor epithelial sloughing (R = 0.31, P < 0.001), preservation-to-surgery time (R = 0.24, P < 0.001), and graft rating (R = -0.28, P < 0.001). Suture-related complications, graft rejection episodes, graft clarity, visual acuity, and refractive outcomes at the final follow-up examination were found to have no correlations with any donor factors. CONCLUSIONS: The use of low-quality donors for DALK increased the rate of epithelial defects and stromal edema immediately postoperatively. However, the donor features had no influence on visual and refractive outcomes and complications.

Penetrating keratoplasty versus lamellar keratoplasty for mustard gas-induced keratitis.

PURPOSE: To compare the outcomes of penetrating keratoplasty (PK) and lamellar keratoplasty (LK) in patients with mustard gas keratitis. METHODS: A total of 78 eyes of 55 patients with mustard gas keratitis were included. Of these eyes, 27 (34.6%) underwent PK and 51 (63.4%) received LK. Keratolimbal allografts were performed in 11 and 30 eyes of the PK and LK groups, respectively. The study groups were compared in terms of best spectacle-corrected visual acuity, refractive error, and keratometry readings. The Kaplan-Meier survival curve and log-rank test were used to evaluate and compare the cumulative incidence of rejection-free graft survival and graft survival in PK and LK. RESULTS: At the time of keratoplasty, the mean patient ages were 40.3 ± 4.5 years and 43.4 ± 8.3 years in the PK and LK groups, respectively (P = 0.08). The patients were followed-up for 53.2 ± 27.5 and 40.4 ± 29.6 months, respectively (P = 0.09). At the last follow-up, the 2 study groups were comparable with respect to best spectacle-corrected visual acuity (P = 0.87), refraction (P = 0.08), and keratometric astigmatism (P = 0.27). At the 33-month follow-up examination, the rejection-free graft survival rates were 33.6% in the PK group and 90% in the LK group, with mean durations of 34.6 and 84.8 months, respectively (P < 0.001). Moreover, the graft survival rates were 77.3% and 91.7%, with mean durations of 67.5 and 76.1 months, respectively (P = 0.03). Three eyes that had received LK underwent PK because of significant interface haziness. CONCLUSIONS: LK is preferred to PK in the majority of mustard gas victims. However, PK should always be performed in certain conditions.

Changing indications and surgical techniques for corneal transplantation between 2004 and 2009 at a tertiary referral center.

PURPOSE: The aim of this study is to report the indications, techniques, and clinical outcomes of corneal transplantation and investigate any changing trends in surgical techniques over a 6 year period. MATERIALS AND METHODS: Records of patients who had undergone any kind of corneal transplantation at Labbafinejad Medical Center, Tehran, Iran, from January 2004 to December 2009 were reviewed to determine the indications and types of corneal transplantation. Postoperative best-corrected visual acuity, refractive error, graft clarity, and complications were reported. RESULTS: During this period, 1859 eyes of 1624 patients with a mean age of 41.3 ± 21.3 years underwent corneal transplantation. The most common indication was keratoconus (38.4%) followed by aphakic/pseudophakic bullous keratopathy (11.7%), previous failed grafts (10.6%), infectious corneal ulcers (10.1%), non-herpetic corneal scars (7.6%), trachoma keratopathy (4.7%), stromal corneal dystrophies (4.6%), post-herpetic corneal scar (3.7%), Fuchs' endothelial dystrophy (0.8%), and congenital hereditary endothelial dystrophy (0.4%). Techniques of corneal transplantation included penetrating keratoplasty (PKP; 70.9%), deep anterior lamellar keratoplasty (DALK; 20.1%), conventional lamellar keratoplasty (LKP; 4.4%), and Descemet's stripping automated endothelial keratoplasty (DSAEK; 2.3%). Over the study period, there was a significant increase in the relative frequency of infectious corneal ulcers, failed grafts, and trachoma keratopathy. Additionally, a significant reduction was observed in PKP and LKP procedures, and volume of DALK and DSAEK increased significantly. At final follow-up, 69.0% of grafts were clear in the PKP group. This figure was 82.6%, 82.7%, and 97.6% in the DALK, LKP, and DSAEK groups, respectively. CONCLUSION: Keratoconus was the most common indication and PKP was the most prevalent technique used for corneal transplantation. However, significant changes in the indications and surgical techniques were observed from 2004 to 2009.

Corneal graft curvature change after relaxing incisions for post-penetrating keratoplasty astigmatism.

PURPOSE: To evaluate change in graft steepness after graft refractive surgery (GRS) consisting of relaxing incisions with or without counterquadrant compression sutures and discover the existing influential factors. METHODS: In this retrospective study, 78 eyes of 76 patients who had received penetrating keratoplasty for keratoconus underwent GRS because of high post-penetrating keratoplasty astigmatism. Any shift in graft curvature was calculated using the keratometric coupling ratio (CR; the ratio of flattening of the incised meridian to steepening of the opposite meridian). Multiple regression analysis was used to investigate the possible effect of age, graft curvature, number of incisions, use of compression sutures, achieved vector astigmatic correction, and total arc length on CR. RESULTS: Mean patient age was 30.1 ± 10.3 years and mean follow-up period after GRS was 40.1 ± 29.0 months. There was a significant increase in average keratometry from 44.79 ± 2.08 diopters (D) preoperatively to 45.65 ± 1.86 D postoperatively (P < 0.001). Mean keratometric CR was 0.62 ± 1.09. Keratometric CR was significantly associated with patient age (R = 0.53, P = 0.04) and preoperative average keratometry (R = 0.61, P = 0.02). However, keratometric CR failed to show any significant correlation with other variables. CONCLUSIONS: A significant increase in graft steepening occurred after GRS, averaging 0.86 D. When both GRS and cataract extraction or phakic intraocular lens implantation are indicated, a staged approach (first GRS followed by phacoemulsification, for example) is advocated to calculate intraocular lens power with accuracy.

Evaluation of relationship between the serum levels of inflammatory mediators and ocular injuries induced by sulfur mustard: Sardasht-Iran Cohort Study.

Ocular damages induced by sulfur mustard (SM) are the important problems in exposed patients. The damaging mechanisms are not clearly understood. In the present study the relationship between the serum levels of inflammatory mediators and ocular injuries induced by SM was evaluated. Bulbar conjunctiva and limbal tissue abnormalities were significantly more frequent in the expose versus control group (P=0.004 and 0.048 respectively). The serum levels of IL-1alpha and TNF-alpha in the exposed group with and without Slit lamp findings were significantly lower than their counterpart in the control group. The serum levels of IL-1beta in the exposed group with Slit lamp findings were significantly lower than their counterpart in the control group. The serum levels of IL-1beta in the controls with Slit lamp findings were significantly higher than the controls without Slit lamp findings. The serum levels of IL-1Ra and MMP-9 in the exposed group with and without Slit lamp findings do not display any significant differences as compared to the similar controls. The serum levels of IL-6 in the exposed group with or without Slit lamp findings were significantly lower than their counterpart in the control group (P=0.048 and 0.008 respectively). The serum titers of the CRP and RF in the exposed group without Slit lamp findings were significantly elevated versus their counterpart in the control group (P=0.004 and 0.011 respectively). The serum levels of these inflammatory cytokines except for IL-1Ra and MMP-9, decreased in SM exposed subject independent of ocular problems. More local studies on the eyes are needed to clarify the exact role of this cytokines in ocular problems of chemical.

Outcomes of augmented relaxing incisions for postpenetrating keratoplasty astigmatism in keratoconus.

PURPOSE: To determine the outcomes of augmented relaxing incisions (relaxing incisions and counter-quadrant compression sutures) as graft refractive surgery (GRS) in keratoconic eyes. PATIENTS AND METHODS: This interventional case series included keratoconic eyes undergoing GRS for intolerable amounts of postpenetrating keratoplasty (PKP) astigmatism. Relaxing incisions were made in the graft-host interface down to Descemet membrane on both sides of the steepest meridian. Interrupted 10-0 nylon compression sutures were added in the opposite meridian to overcorrect astigmatism. Selective suture removal was initiated after 3-6 weeks to achieve tolerable amounts of astigmatism. Best-corrected visual acuity and refractive and keratometric astigmatisms were compared before and after the operation using simple subtraction and vector analysis methods. RESULTS: Overall, 77 eyes of 77 patients including 51 (66.2%) male and 26 (33.8%) female subjects with mean age of 30.0 +/- 10.2 years at the time of PKP were studied. Average follow-up was 61.5 +/- 33.5 months after PKP and 40.8 +/- 29.3 months after GRS. Mean best-corrected visual acuity improved from 0.31 +/- 0.26 logMAR (20/40) before GRS to 0.18 +/- 0.12 logMAR (20/30) postoperatively (P < 0.001). Mean preoperative and postoperative values for refractive astigmatism, keratometric astigmatism, and spherical equivalent refractive error were 6.8 +/- 1.4 and 3.9 +/- 1.6 diopters (D) (P < 0.001), 7.9 +/- 1.9 and 4.5 +/- 2.2 D (P < 0.001), and -2.0 +/- 2.9 and -3.24 +/- 2.8 D (P < 0.001), respectively. Vector analysis demonstrated that refractive and keratometric astigmatisms were reduced by 4.8 and 5.9 D, respectively. CONCLUSIONS: GRS using augmented relaxing incisions reduces post-PKP astigmatism in keratoconic eyes; however, it causes a slight myopic shift.

Outcomes of epikeratoplasty for advanced keratoglobus.

PURPOSE: To determine the visual and anatomic outcomes of epikeratoplasty in keratoglobus. METHODS: In an interventional case series, 7 eyes of 6 patients with keratoglobus (KGB), 5 to 39 years of age, underwent epikeratoplasty. Three patients (3 eyes) had blue sclera, joint hypermobility, and consanguineous parents; 3 other patients (4 eyes) had only KGB. In the blue sclera group, all patients had lost the fellow eye because of minor trauma. We used a corneo-scleral button 1 mm larger than corneal diameter as an onlay graft. Orbscan pachymetry was performed before and 3 months after surgery. RESULTS: Mean visual acuity was 20/400 preoperatively and improved to 20/160 postoperatively. Mean central corneal thickness was 200 microm preoperatively, which increased to 800 microm after surgery. Epithelial inclusion cysts developed in 1 patient. Severe interface vascularization was observed in 1 eye of the blue sclera group, which had total Descemet membrane detachment before epikeratoplasty. Neurotrophic ulcer occurred in 1 case, which improved with tarsorrhaphy, punctal occlusion, and medical therapy. CONCLUSION: Epikeratoplasty is a safe and effective procedure in preserving ocular integrity and increasing visual acuity in patients with keratoglobus and should be considered before corneal perforation, which often results in loss of an eye.

Lamellar crescentic resection for pellucid marginal corneal degeneration.

PURPOSE: To evaluate the results of lamellar crescentic resection in pellucid marginal corneal degeneration. METHODS: Patients with pellucid marginal corneal degeneration who underwent lamellar crescentic resection from 1995 to 2000 at Labbafinejad Medical Center were assessed. Diagnosis was based on clinical findings of slit-lamp microscopy and confirmed by corneal topography and pachymetry. RESULTS: Fifteen eyes of nine patients (six male and three female) were operated. Mean patient age was 32 years (range 25 to 41 yr). Preoperatively, best spectacle-corrected visual acuity was 20/200 to 20/500 with a range of 12 to 26 D of against-the-rule astigmatism (mean 19.00 D). Follow-up ranged from 13 to 57 months (mean 35 mo). Postoperatively, patients had with-the-rule astigmatism: mean 16.00 D at 6 weeks and 10.50 D at 6 months. In the second postoperative year, mean with-the-rule astigmatism was 4.30 D. Best spectacle-corrected visual acuity was 20/40 in 71% of eyes at final follow-up. No significant complications occurred during the study period. CONCLUSION: Lamellar crescentic resection was a safe and effective non-penetrating surgical method to manage pellucid marginal corneal degeneration, however, visual recovery was relatively prolonged.