Femtosecond laser - Assisted cataract surgery in pediatric pyramidal anterior polar cataract.

PURPOSE: The purpose of this report is to describe the successful utilization of femtosecond laser assisted cataract surgery (FLACS) in a rare case of pyramidal anterior polar cataract in a female child. OBSERVATIONS: The patient is a 6 years old girl that presented to the cornea clinic with a unilateral pyramidal cataract that was deemed to be visually significant, and therefore required cataract extraction and intraocular lens implantation surgery. FLACS was proposed and mother consented to proceed with the surgery. The femtosecond laser technology enabled precise completion of a central capsulotomy around the protruding pyramidal capsular lesion. CONCLUSIONS AND IMPORTANCECONCLUSION: Various capsulorhexis techniques have been described and are used in pediatric cataracts including manual, can opener, vitrectorhexis, and laser, but none has become a standard. We propose the use of femtosecond laser for cataract extraction in cases of pediatric pyramidal cataracts, and hereby provide the first case report of such. The laser is a safe method for capsulorhexis construction and offers an additional advantage of intraoperative anterior segment OCT image guidance with visualization of the pyramidal lesion.

Predictive factors of Boston Type I Keratoprosthesis outcomes: A long-term analysis.

PURPOSE: To study the long-term visual- and device retention-related outcomes and complications of the Boston Type I Keratoprosthesis (KPro). METHODS: Single-center, retrospective cohort study of all patients undergoing KPro implantation from February 2007 to April 2014 with at least 5 years of follow-up. RESULTS: 68 eyes from 65 patients underwent KPro implantation during the study period. At 5 and 10 years, the probability of maintaining or improving visual acuity (VA) was 75.0% and 66.7%, respectively, and the probability of KPro retention was 89.2% and 89.2%, respectively. Initial device retention rate at 10 years was significantly lower in those with underlying ocular surface disease (46.8% [30.6-63.2] vs 75.8% [61.0-90.7], P = 0.03), while other baseline characteristics showed no significant association. Final VA was more likely to be stable or improved in patients with fewer failed grafts (2 [1-6] vs 3 [1-6], P < 0.01), and a final VA of 20/200 or better was more likely in primary KPro eyes (44.8% [26.7-62.9] vs 19.4% [6.5-32.3], P = 0.03). Combined KPro-vitrectomy eyes were more likely to have stable or improved final VA than non-vitrectomy eyes (88.5% [76.2-100.0] vs 64.1% [49.1-79.1], P = 0.04). All complications had increasing incidence beyond 5 years; in particular, corneal melt, surgical glaucoma interventions, and endophthalmitis tended to have late presentations, with 79.0%, 78.6%, and 88.9% of these complications occurring beyond one year, respectively. CONCLUSIONS: KPro devices show favorable long-term visual and retention outcomes in select patients. Careful long-term, multidisciplinary follow-up is warranted to address potential complications.

Management of Congenital Aniridia-Associated Keratopathy: Long-Term Outcomes from a Tertiary Referral Center.

PURPOSE: To report the outcomes of medical and surgical management for congenital aniridia-associated keratopathy (AAK) over a long-term follow-up period. DESIGN: Retrospective, comparative case series. METHODS: Medical records of patients diagnosed with congenital aniridia were retrospectively reviewed. Age, sex, ethnicity, follow-up time, AAK stage, noncorneal abnormalities, ocular surgeries, and complications were recorded. The visual acuity equivalent (VAE), approximate Early Treatment Diabetic Retinopathy Study (appETDRS) letter score, was calculated using recorded Snellen visual acuities. RESULTS: A total of 92 eyes of 47 patients (31 females) with mean age of 48.0 ± 18.0 years and mean follow-up of 78.6 ± 42.2 months were included. At the initial visit, 12 eyes (13%) were classified as Stage I AAK, 33 eyes (35.9%) were Stage II, 25 eyes (27.2%) were Stage III, 17 eyes (18.5%) were Stage IV, and 5 eyes (5.4%) were Stage V. Limbal stem cell transplantation (LSCT) and Boston keratoprosthesis (KPro) were frequently performed in eyes with Stages III-V. These advanced corneal surgeries significantly improved the median (95% confidence interval [CI]) of calculated appETDRS scores from 2 (0-20) to 26 (15-41) (Snellen values, 20/20,000 to 20/300; P = 0.0004). Patients with earlier Stages (I-II) of AAK were managed medically and had stable visual acuity through their final visits (appETDRS score of 26 [20-35] to 35 [26-35]; Snellen, 20/300 to 20/200; P > 0.05). The appETDRS VAE was significantly improved from 20 (0-35) to 30 (20-55), Snellen, 20/400 to 20/250, following LSCT (P = 0.021) and from 2 (0-20) to 2 (0-41) after KPro; Snellen, 20/20,000 VAE but with improved 95% CI after follow-up (P = 0.019). CONCLUSIONS: With proper characterization and staging of AAK, individualized medical and advanced surgical interventions preserves and improves visual acuity.

Staged ocular fornix reconstruction for glaucoma drainage device under neoconjunctiva at the time of Boston type 1 Keratoprosthesis implantation.

PURPOSE: Glaucoma is the leading cause of vision loss in eyes with Boston Keratoprosthesis (KPro). Glaucoma drainage devices (GDDs) have been shown to be effective in controlling glaucoma with KPro. Cicatricial conjunctival disease with forniceal shortening is a major challenge and limitation to the use of GDD. In our series, we report the success of fornix reconstruction in cicatricial ocular surface disease as a staged procedure prior to a combined KPro/GDD surgery. METHODS: Retrospective case series involving 4 eyes with surface cicatricization. Three patients with chemical burns and one patient with Ectrodactyly Ectodermal Dysplasia-Clefting syndrome. Preoperative data, surgical interventions, and clinical outcomes were reviewed. CONCLUSION: This series represents the first report of fornix reconstruction for combined KPro/GDD surgery. Fornix reconstruction with the aid of AMT with or without OMM grafting is a relatively safe and effective way to manage complex cicatricial surface disease associated with corneal scarring and glaucoma, allowing for subsequent successful implantation of GDD and KPro in cases that were otherwise poor surgical candidates.

Intraocular Light Scatter in Eyes With the Boston Type 1 Keratoprosthesis.

PURPOSE: The Boston keratoprosthesis (KPro) is the most commonly used artificial cornea. It has been proven to be successful for severe corneal disease not amenable to keratoplasty. We have observed our patients reporting debilitating glare despite attaining good visual acuities. This motivated us to objectively measure light scatter in eyes with a KPro. METHODS: Light scatter was measured in 21 eyes with the Boston type 1 KPro with a VA of 20/150 or better and was compared with 13 healthy control eyes using the Oculus C-Quant device (Arlington, WA). Eyes were also measured using an occluder contact lens. RESULTS: Light scatter (quantified as the logS value) was significantly higher in the KPro group than in the control (2.34 ± 0.15 vs. 1.29 ± 0.17, P < 0.001). The polymethylmethacrylate (PMMA) KPro group (16 eyes, logS 2.49 ± 0.19) but not the titanium group (5 eyes, logS 1.87 ± 0.15) had significantly higher light scattering than the control. The use of an occluder contact lens significantly decreased light scatter in eyes with a PMMA backplate (n = 11, logS 1.71 vs. 2.42, P = 0.028). CONCLUSION: This study confirms that intraocular light scatter is increased in KPro eyes. Possibly because of its opaque nature, the titanium backplate model seems to produce less light scatter than does the PMMA model. Occluder contact lenses reduced light scatter significantly in the PMMA KPro and could be a treatment option for symptomatic patients.

Five year outcomes of Boston type I keratoprosthesis as primary versus secondary penetrating corneal procedure in a matched case control study.

Despite improved retention and reduced complication rates paving the way for the current expansion of applications and surge in prevalence for the Boston type I Keratoprosthesis (KPro), the most frequent indication for its implantation today remains prior graft failure. The purpose of this study is to evaluate the long-term outcomes of primary KPro and compare to secondary implantation in a matched cohort study. This study included patients who underwent KPro implantation in a single center by two surgeons between July 2008 and October 2014. All eyes with KPro implantation as the primary procedure with a minimum follow up of 12 months were matched with eyes with same preoperative diagnoses that underwent secondary KPro implantation. Main outcomes included visual acuity and device retention. A total of 56 eyes were included with 28 eyes in each group. Mean follow up was 5.0 years for both groups. Twenty-nine percent (8) of the eyes in the primary group had a diagnosis of chemical or thermal injuries, 25% (7) aniridia, 18% (5) autoimmune disease, 4% (1) infectious keratitis/neurotrophic cornea, 7% (2) gelatinous corneal dystrophy, 7% (2) ectrodactyly ectodermal dysplasia/limbal stem cell deficiency, and 11% (3) uveitis/hypotony. Sixty-one percent (17) of the eyes in the primary group and 39% (11) in the secondary group maintained a final best-corrected visual acuity of 20/200 or better at a mean follow up of 5.0 years; the probability of maintaining best-corrected vision is 0.83 and 0.49 for primary and secondary groups at 5.0 years (p = 0.02). There is no statistically significant difference between groups in device retention (p = 0.22) or postoperative complication rates (p >0.05). This study demonstrates that Boston KPro implantation may be successful as a primary procedure in patients at high risk of failure with traditional penetrating keratoplasty. The device has a good long-term retention rate and visual outcomes are promising however a larger study is needed for more definitive results.

COMPARISON OF VISUAL AND ANATOMICAL OUTCOMES OF EYES UNDERGOING TYPE I BOSTON KERATOPROSTHESIS WITH COMBINATION PARS PLANA VITRECTOMY WITH EYES WITHOUT COMBINATION VITRECTOMY.

PURPOSE: To determine whether 1-year visual and anatomical results after surgery combining pars plana vitrectomy, Boston keratoprosthesis, and a glaucoma drainage device as needed are similar, better, or worse than Boston keratoprosthesis initial implantation alone. METHODS: We performed a retrospective review of adult patients undergoing Boston keratoprosthesis at our institution. Visual acuity outcomes, anatomical results, and complication rates of patients undergoing combination surgery (including pars plana vitrectomy and a posterior glaucoma drainage device) were compared with those undergoing keratoprosthesis placement alone. RESULTS: There were 70 eyes in the keratoprosthesis alone group and 55 eyes in the keratoprosthesis with pars plana vitrectomy group. Mean follow-up durations were 54.67 months in the keratoprosthesis alone group and 48.41 months in the combination group. Baseline mean Snellen equivalent visual acuities were worse for the combination group compared with the keratoprosthesis alone group (P = 0.027). Visual acuities improved postoperatively by 1 month after keratoprosthesis implantation for both groups and improved three or more lines of Snellen acuity in the majority of eyes for both groups (≥72% by 12 months). Eyes undergoing pars plana vitrectomy had lower rates of de novo (P = 0.015) and significantly lower rates of secondary procedures (P = 0.002) at 1 year. One year complications rates for retroprosthetic membrane formation, retinal detachment, hypotony, cystoid macular edema, epiretinal membrane formation, endophthalmitis, and corneal melting were similar for both groups. CONCLUSION: Compared with keratoprosthesis alone, combining keratoprosthesis with pars plana vitrectomy and a glaucoma drainage device as needed, resulted in lower rates of de novo glaucoma, lower rates of additional surgical procedures, similar visual acuity outcomes at 1 year, and did not result in higher complication rates.

Retroprosthetic Membrane Formation in Boston Keratoprosthesis: A Case-Control-Matched Comparison of Titanium Versus PMMA Backplate.

PURPOSE: Retroprosthetic membrane (RPM) formation is the most common complication after Boston type 1 keratoprosthesis (KPro) implantation. It affects visual acuity and can predispose to corneal melt. Two KPro backplate materials are available: titanium and polymethyl methacrylate (PMMA). This study investigates the influence of the KPro backplate material on visually significant RPM formation. METHODS: A retrospective case-control-matched study involving 40 patients; 20 eyes implanted with a titanium backplate KPro were case-matched with 20 eyes implanted with a PMMA backplate KPro between 2007 and 2015 with 1-year minimum follow-up. RESULTS: The mean follow-up duration was 28.1 ± 8.9 and 53.6 ± 24.3 months in the titanium and PMMA groups, respectively. At 12 months postoperatively, 7 eyes with titanium and 6 eyes with PMMA backplates developed a visually significant RPM. By the end of the study, a total of 11 eyes with titanium and 9 eyes with PMMA KPros developed a visually significant RPM. There was no statistically significant difference between both groups. Three of 11 eyes with titanium KPros that had a visually significant RPM required surgical membranectomy, whereas all eyes with PMMA KPros were successfully treated with the yttrium-aluminum-garnet laser. Recurrence of RPMs was found in 7/11 eyes in the titanium group and 2/9 eyes in the PMMA group with no statistical significance. CONCLUSIONS: Titanium backplate KPros do not significantly reduce RPM formation compared with PMMA backplate KPros in a case-control-matched setting. A larger prospective study is warranted to evaluate comparative long-term performance and guide newer designs.