Outcomes of Descemet's membrane keratoplasty in graft failure after penetrating keratoplasty.

PURPOSE: To analyze the outcomes and identify the risk factors of failure in Descemet's membrane endothelial keratoplasty (DMEK) for graft failure after penetrating keratoplasty (PKP). METHODS: Medical records and surgical videos of patients who underwent DMEK for graft failure after PKP were reviewed in this retrospective study. Demographic data, the indication for PKP, number of previous PKPs, duration between the last PKP and graft failure, graft diameter at the last PKP, best-corrected visual acuity (logMAR) before and after DMEK, preoperative additional ocular diseases, and intraoperative and postoperative complications were recorded. Descemet's membrane (DM) attachment was examined on the first day and the first month, postoperatively, and at the last follow-up visit. The patients were divided into two groups according to DM attachment at the last visit (group 1, patients with attached DM; group 2, patients with DM detachment). RESULTS: Twenty eyes of 20 patients were included in this study. At the last follow-up visit, DM was attached in 13 (65%) patients (Group 1) and detached in 7 (35%) cases (Group 2). The BCVA was improved significantly after DMEK in all patients (2.10 ± 0.4, preoperatively; 1.09 ± 0.8, postoperatively; p = 0.005). There were no significant differences between groups, in terms of age, the number and indication for PKP, the time between the last PKP and DMEK, or history of glaucoma. PKP was performed in all patients in group 2. CONCLUSION: DMEK is a feasible option with fast visual recovery and a low risk of complications in patients with graft failure after PKP. We found no risk factors for the DM graft detachment, so larger studies are needed to analyze intraoperative or donor-related factors as well.

Effects of Systemic Diseases on Graft Preparation in Descemet Membrane Endothelial Keratoplasty.

OBJECTIVES: To evaluate the effects of the systemic diseases and drugs of the donor on Descemet membrane (DM) graft preparation. METHODS: Seventy-eight corneas of 58 donors, of whom the DM grafts were used in Descemet membrane endothelial keratoplasty (DMEK) surgery, between January 2018 and January 2020, were enrolled in this retrospective study. The hospital records of the donors were analyzed. Age, sex, blood type, systemic diseases, and drugs; complete blood count; biochemistry panel for liver and kidney functions in the past 48 hours; and the drugs used in the hospital, if any, in the past 24 hours were recorded. The grafts with tears that occurred while preparation were included in group 1, and the successful grafts with no tears were included in group 2. RESULTS: There were no statistically significant differences in the characteristics of the donors between groups. However, breast cancer and the use of sevelamer were found to be significantly higher in group 1 ( P =0.010, P =0.033, respectively). No statistically significant difference in the use of other drugs was found between groups. CONCLUSION: Although diabetic donors have been reported to be inappropriate candidates for the preparation of DM grafts for DMEK, most of the donors with several systemic diseases including diabetes can be used in DMEK surgery, with the right technique in DM graft preparation.

Clinical results of combined penetrating keratoplasty and vitreoretinal surgery.

PURPOSE: The study aimed to assess the anatomical and functional success rates of penetrating keratoplasty with temporary keratoprosthesis-assisted vitreoretinal surgery. METHODS: This retrospective study included 15 eyes of 14 patients, recording demographic characteristics, pre-operative anterior and posterior segment pathologies, intraoperative complications, postoperative graft status, retinal attachment, and complications and evaluating anatomical and functional success rates. RESULTS: The mean follow-up period was 29.8 ± 19.1(6-60) months. The most common pre-operative corneal pathology was graft abscess (7 eyes [46.7%]), and the most common diagnosis of the posterior segment was endophthalmitis (7 eyes [46.7%]). Five (33.3%) cases had visual acuity between 0.001-0.08. Pre-operative endophthalmitis was diagnosed in all five cases with anatomical failure.Conclusion: Temporary keratoprosthesis-assisted vitreoretinal surgery with penetrating keratoplasty is an effective method to treat acute/subacute pathologies of the concomitant anterior and posterior segment. However, results may vary on a case-by-case basis. Pre-operative endophthalmitis is a poor prognostic factor for long-term success.

Effective Cannula Vacuuming Maneuver to Unfold the Descemet Membrane Graft.

OBJECTIVES: To present the cannula vacuuming maneuver (CVM) in the Descemet membrane endothelial keratoplasty (DMEK) and to investigate the efficacy of CVM in reducing the unfolding time (UT) of the graft in cases with an unstable anterior chamber (AC). SUBJECTS/METHODS: Forty-four eyes of 44 patients, who underwent DMEK at the ophthalmology clinic of a training and research hospital, were included in this retrospective study. Surgical videos and patient charts were examined retrospectively. In 21 cases, only no-touch technique maneuvers were used (group 1), and in 23 cases, CVM was used in addition to the no-touch technique (group 2). Demographic data, the status of AC, graft diameter, width, and formation of graft rolls and UT were recorded and compared between the groups. The causes of increased UT and the reason for using CVM were investigated in group 2. RESULTS: Although an unstable AC was observed more frequently in group 2, the difference between the groups was not statistically significant (P=0.054). Unfolding time of rolls in group 2 was significantly shorter than group 1 (P=0.040). CONCLUSION: Cannula vacuuming maneuver shortens the UT of the graft roll in the AC and facilitates the graft unfolding maneuvers in complicated cases.

Use of viscoelastic substance for preventing Descemet's membrane rupture in deep anterior lamellar keratoplasty.

PURPOSE: This study aimed to investigate the effect of using a viscoelastic substance in Descemet's membrane rupture in "double bubble" deep anterior lamellar keratoplasty. METHODS: The medical records and videos of surgeries of 40 patients who underwent surgery between January 2014 and July 2015 were retrospectively evaluated. The patients were divided into two groups: 20 patients whose perforation of the posterior stromal wall was performed without administration of any viscoelastic substance (group 1) and 20 patients whose perforation of the posterior stromal wall was performed with administration of viscoelastic substance onto the posterior stroma (group 2). The Descemet's membrane perforation rate was compared between groups. RESULTS: Perforation of the Descemet's membrane was observed in 12 (60.0%) patients in group 1 and only three (15.0%) patients in group 2. This difference was statistically significant (p=0.003). Only one (5%) patient in group 2 had macroperforation during the procedure, and the surgery was converted to penetrating keratoplasty. Eleven (55.0%) patients in group 1 had macroperforation of Descemet's membrane, and surgeries were converted to penetrating keratoplasty. This difference between the groups was statistically significant (p=0.001). CONCLUSIONS: Administering a viscoelastic substance onto the posterior stromal side just before puncture is an effective method to decrease the risk of Descemet's membrane perforation in deep anterior lamellar keratoplasty.

Penetrating Keratoplasty With Sutureless Intrasclerally Fixated Intraocular Lens.

OBJECTIVES: In this retrospective study, we reviewed the use of penetrating keratoplasty with sutureless intrasclerally fixated intraocular lens implantation in a closed anterior chamber in patients with several corneal pathologies and aphakia. MATERIALS AND METHODS: The medical records of 6 patients, who underwent the procedure, were reviewed. In the procedure, lamellar scleral tunnels at the 2- and 8-o'clock positions were created with a microvitreoretinal blade, 1.5 mm away from the limbus. Two 27-gauge bent needles were passed, first horizontally, through these tunnels, and then vertically, which allowed them to enter the posterior chamber and to be left in position. Partial thickness trephination was made, and anterior stroma was removed where necessary. An incision was made at the 11-o'clock position, where the trephination was made, which was then extended to both sides for about 6 mm with corneal scissors. From the superior incision, the anterior haptic of a 3-piece intraocular lens was pushed through the needle at the 2-o'clock position, then the posterior haptic was pushed through the needle at the 8-o'clock position, and both haptics were removed through the sclera. Both ends were cauterized and placed into the sclera. Residual stroma was removed, and the donor graft was sutured. RESULTS: At the last follow-up visit, the mean bestcorrected visual acuity was significantly increased. No serious complications were seen, with the exception of increased intraocular pressure in 3 patients. CONCLUSIONS: Penetrating keratoplasty with sutureless intrasclerally fixated intraocular lens implantation can be used safely in patients with aphakia. With this technique, the globe stabilization can be maintained, and the trauma to the donor graft endothelium can be minimized.

Long-term outcomes of therapeutic penetrating keratoplasty for microbial keratitis in a tertiary care center in Turkey.

PURPOSE: To present the long-term results of therapeutic keratoplasty for microbial keratitis in moderate to advanced phases. METHODS: The medical records of 44 patients who underwent therapeutic keratoplasty for microbial keratitis at the ophthalmology clinic of a training and research hospital between June 2012 and March 2018 were reviewed in this retrospective study. RESULTS: Of the 65 patients that underwent TPKP, 44 eyes of 44 patients met the inclusion criteria and enrolled in this study. The most commonly found predisposing factor for keratitis was a history of trauma (n = 17, 38.6%), and most of them had occurred with a vegetative matter (n = 14, 31.8%). The most common clinically suspected cause was fungal (n = 17, 38.6%) followed by bacterial (n = 12, 27.3%). In 26 (59.1%) cases, the causative microorganism could not be proved with a microbial culture. The most common causative microorganism was Staphylococcus spp. (n = 4, 9.1%), followed by Fusarium solanii (n = 3, 6.8%). The mean follow-up time was 42 (range 12-54) months. At the last follow-up visit, anatomical success was achieved in 40 (90.9%) cases and the BCVA of more than half of the patients was over 1.0 (logMAR, n = 24, 54.5%). Most commonly seen complication was found to be secondary glaucoma (n = 19, 43.2%), followed by cataracts (n = 9, 34.6%) and graft rejection (n = 12, 27.3%). CONCLUSIONS: TPKP offers a definitive solution in the management of microbial keratitis with high rates of anatomical and functional success. However, secondary glaucoma is the most common complication after TPKP, which was seen in almost half of the patients.

Descemet membrane endothelial keratoplasty and intraocular lens implantation in cases of aphakic bullous keratopathy.

Purpose: To present the results of a modified sutured transcleral or sutureless intrascleral three-piece foldable intraocular lens (IOL) implantation with Descemet membrane endothelial keratoplasty (DMEK) in cases of aphakic bullous keratopathy (ABK) with inadequate capsular support.Methods: Twenty-one eyes of 21 patients with ABK and inadequate capsular support who underwent DMEK with three-piece foldable IOL implantation from September 2015 to June 2018 were analyzed, retrospectively. Two techniques were used in IOL implantation; sutureless intrascleral fixation of the IOL (ISF-IOL) and sutured transscleral-fixated IOL (TSF-IOL) implantation.Results: Rebubblings due to the graft detachment were needed in 9 (43%) of 21 eyes in the early postoperative period. At the last follow-up visit, 18 (85.7%) of DM grafts were attached. Any complication related to IOL implantation was not observed in the ISF-IOL cases. Exposure of the fixation suture in 1 (25%) of 4 TSF-IOL cases was seen, postoperatively. The increase in the mean best-corrected visual acuity (BCVA) at the last follow-up visit was statistically significant when compared to the mean preoperative BCVA (p < .001). The mean preoperative central corneal thickness was decreased from 883.3 ± 111.8 (700-1150) µm to 582.3 ± 118.2 (490-990) µm at the last follow-up visit (p < .001).Conclusion: DMEK combined with sutureless/sutured three-piece foldable IOL implantation appears to be a feasible method for the management in ABK without adequate capsular support. A faster visual recovery can be obtained with the techniques presented.

Interface fluid syndrome secondary to endothelial failure due to toxic anterior segment syndrome after cataract surgery.

PURPOSE: To present a case of previous laser in situ keratomileusis with interface fluid syndrome secondary to toxic anterior segment syndrome following cataract surgery. CASE REPORT: A 52-year-old woman, complaining blurred vision in her right eye for 18 months after cataract surgery, was referred to our clinic. She was diagnosed with toxic anterior segment syndrome, postoperatively, which resolved in 3 days. She had a history of laser in situ keratomileusis surgery 15 years ago. Slit-lamp examination of the right eye showed corneal haze, limited to laser in situ keratomileusis flap. The patient was diagnosed with interface fluid syndrome secondary to endothelial decompensation due to toxic anterior segment syndrome. Descemet's membrane endothelial keratoplasy was performed along with full thickness fenestrations in the laser in situ keratomileusis flap to the right eye of the patient. The fluid was resolved in 1 week and visual acuity was improved rapidly. CONCLUSION: This case shows the importance of considering the diagnosis and determining the specific etiology of interface fluid syndrome, even years after the laser in situ keratomileusis surgery, when endothelial cell function has been compromised with any factor, such as intraocular surgery and its complications.

A practical and easy surgical technique for recovery of an incarcerated haptic.

PURPOSE: To present a surgical intervention for a posterior haptic trapped between the cartridge and plunger during intraocular lens (IOL) implantation. MATERIALS AND METHODS: Posterior haptic incarceration was detected in 36 cases during implantation of a one-piece foldable IOL during cataract surgery with phacoemulsification. In 11 of the patients (Group 1), recovery was achieved by forcibly pulling out the incarcerated posterior haptic. In 25 cases (Group 2), the haptic was recovered by using an MVR knife to cut the cartridge tip from the bottom up parallel to the trapped haptic. RESULTS: In Group 1, tears were seen on the incarcerated haptic in all cases (100%). In Group 2, the procedure was successful in all 25 cases and there was no accidental cutting of the haptic. In all cases, the surgeries were completed with the recovered IOL in Group 2. CONCLUSIONS: Posterior haptic incarceration in cataract surgery can be solved by the simple and easy method of cutting the cartridge tip from the bottom upwards and releasing the haptic.

Descemet membrane endothelial keratoplasty (DMEK): intraoperative and postoperative complications and clinical results.

PURPOSE: To evaluate the complications and clinical results of Descemet membrane endothelial keratoplasty (DMEK) in patients with endothelial failure that occurred during the learning curve of a surgeon. METHODS: Fifty eyes of 50 patients with DMEK and ≥6 months of follow-up were included. The patients were divided into the first 25 (group 1) and the second 25 (group 2) procedures performed by the surgeon. Best corrected visual acuity (BCVA), central corneal thickness (CCT), unfolding time of the Descemet membrane (DM) graft, and intraoperative and postoperative complications were compared between groups. RESULTS: The differences in postoperative increase of BCVA (p=0.595) and decrease of CCT (p=0.725) in the two groups were not significant. The unfolding time of the DM was longer in group 1 than in group 2 (p=0.001). Primary graft failure occurred in three patients in group 1 and none in group 2. At the last visit, 42 (85.7%) of patients' corneas were clear, with significant difference between groups (p=0.584). A patient in group 1 with a history of pars plana vitrectomy, inferior iridectomy, and fluid as a tamponade experienced drop of the DM graft into the iridectomy space. All other intraoperative complications occurred in group 1. CONCLUSIONS: Occurrence of intraoperative and postoperative complications was increased in patients with coexisting ocular pathology or complicated endothelial dysfunction and during the surgeon's learning curve of DM endothelial keratoplasty procedures.

Effects of age and gender on macular thickness in healthy subjects using spectral optical coherence tomography/scanning laser ophthalmoscopy.

PURPOSE: To examine healthy subjects for normal macular thickness values and determine the effects of gender and age in a Turkish population, using spectral optical coherence tomography/scanning laser ophthalmoscopy (OCT/SLO). MATERIAL AND METHOD: Six hundred fourteen eyes of 307 subjects with no history of ocular diseases and normal ophthalmic examination were recruited in this cross-sectional, prospective study. The participants were divided into three groups based on age (between 20 and 29 years: group 1, between 30 and 39 years: group 2, between 40 and 49 years: group 3). All subjects were scanned with spectral OCT/SLO, performed by one examiner to acquire the retinal thickness map in the ETDRS grid, and values were recorded for nine sectors, and effects of age and gender were evaluated. RESULTS: When all the subjects were evaluated, the thicknesses were lower in women than men in all sectors (p < 0.001). When divided in groups based on age, this difference remained only in the outer segments. However, the differences in outer layers, except outer nasal layer, were thicker in women in group 3 when compared to others in group 3. When compared between groups, only central thickness in group 3 was shown to be higher than group 1 (p = 0.06). There was no significant difference of thicknesses in any sector when compared right and left eyes of all subjects. CONCLUSIONS: The study reports the variation in retinal thickness between age and gender in a relatively large sample of a Turkish population. It is important to consider these effects while interpreting the OCT images to make an appropriate diagnosis in retinal diseases.

Effects of GH/IGF-I Axis on Retinal Vascular Morphology: Retinal Vascular Characteristics in a Clinical Setting with Severe IGF-I Deficiency.

BACKGROUND: The purpose of this study was to assess retinal vascular characteristics of patients with Laron syndrome (LS) as a genetic model of IGF-I deficiency before and after rhIGF1/IGFBP3 treatment and to compare them with healthy controls. METHODS: A total of 28 subjects (11 LS, and 17 controls) were enrolled. Patients with LS received combined rhIGF1/rhIGFBP3 1-2 mg/kg/d in a single dose and digital fundus imaging was performed. The number of branching points and tortuosity of retinal vessels were studied. Pre- and post-treatment findings were compared with each other and with controls. RESULTS: The number of branching points was significantly lower in patients with LS in comparison to controls (12.73 ± 3.41, and 17.47 ± 5.82 respectively, p = 0.012). This difference persisted after treatment (12.09 ± 2.66 post-treatment LS versus controls, p = 0.017). Tortuosity indices of nasal arteries (NA) were significantly less in LS than that of controls (upper NA 1.07 ± 0.04 and 1.12 ± 0.06 respectively p = 0.022; lower NA 1.07 ± 0.03 and 1.13 ± 0.07 respectively, p = 0.004). This difference also persisted following treatment (p < 0.05). Remaining vessels did not differ in tortuosity index. There was no significant difference of tortuosity index and number of branching points before and after treatment in patients with LS. CONCLUSION: Retinal vascular development may be adversely affected in the setting of severe IGF-I deficiency confirming a major role for GH/IGF-I axis during retinal vascular development in humans antenatally. Resolution of IGF-I deficiency following birth using rhIGF1, however, may not reverse these changes, suggesting that IGF-I may be necessary but insufficient by itself for postnatal angiogenesis.

Intraocular Pressure Characteristics of Exfoliative Glaucoma and Exfoliation Syndrome as Determined With the Water Drinking Test.

PURPOSE: To investigate the intraocular pressure (IOP) characteristics of patients with exfoliation glaucoma (XFG) and exfoliation syndrome (XFS) during the water drinking test (WDT). METHODS: This was a prospective observational study undertaken at an academic setting. Consecutive patients with XFG whose office IOP levels were <21 mm Hg, normotensive XFS patients, and control subjects underwent WDT, which involved ingestion of 1 L of water within 5 minutes. The IOP was measured before and 4 times after water ingestion at 15-minute intervals. Maximum IOP (IOPmax), mean IOP (IOPmean), IOP increase (IOPΔ) from baseline IOP to IOPmax, and percentage of IOP fluctuation (IOPfluct) during the WDT were compared across groups. One-way analysis of variance (ANOVA) test or the Kruskal-Wallis test was used for comparisons. RESULTS: The age, gender ratios, visual acuity level, central corneal thickness, and office IOP levels were similar between the 3 groups. As compared with patients with XFS and controls, XFG patients revealed significantly higher values for all IOP measurements at 15 minutes intervals as well as IOPmax (25.1±4.0 mm Hg, 18.7±2.8 mm Hg, 18.6±2.5mm Hg; P<0.001), IOPmean (22.6±3.3mm Hg, 17.2±2.6 mm Hg, 17.2±2.4 mm Hg; P<0.001), IOPΔ (9.2±3.4 mm Hg, 4.4±2.1 mm Hg, 3.7±1.5 mm Hg; P<0.001), and IOPfluct (60.1±24.0%, 33.4±20.0%, 25.7±11.3%; P<0.001). CONCLUSIONS: Medically treated XFG patients, but not XFS subjects, reveal significant IOP elevations during WDT indicative of impaired trabecular outflow facility.

Investigation of retinal nerve fiber layer thickness in patients with neurofibromatosis-1.

PURPOSE: To compare the optical coherence tomography (OCT) findings of neurofibromatosis-1 (NF-1) patients with/without optic pathway glioma (OPG) with those of healthy controls. METHODS: Ten patients with NF-1, 17 patients with NF-1-associated OPGs, and 17 control subjects were included in the study. Retinal nerve fiber layer (RNFL) and macular thickness findings measured with Stratus OCT were compared between the groups. RESULTS: The average RNFL thickness was significantly lower in the OPG group (76.72 ± 22.16 µm) than in the controls (108.89 ± 9.92 µm) and NF-1 patients without OPGs (111.17 ± 12.13 µm) (p < 0.001). The macular volume was also found to be lower in NF-1 patients with OPG (6.41 ± 0.66 mm(3)) than in the healthy controls (7.19 ± 0.36 mm(3); p = 0.001) and NF-1 patients without OPGs (7.25 ± 0.26 mm(3); p = 0.005). Following this analysis the OPG group was further subdivided into two categories: OPG patients with normal visual acuity (VA) and OPG patients with decreased VA. The statistical analysis was repeated for these four subgroups, revealing that while the decrement in the average RNFL thickness was significant for both OPG groups that in the macular volume was only significant for OPG patients with decreased VA. CONCLUSION: The results of our study suggest that RNFL thinning can be a helpful marker for the detection of OPGs in NF-1 patients. Larger studies with longitudinal data are required to confirm the role of OCT in the diagnosis and follow-up of these patients.

Association of LOXL1 gene polymorphisms with exfoliation syndrome/glaucoma and primary open angle glaucoma in a Turkish population.

PURPOSE: To investigate the association of lysyl oxidase like 1 (LOXL1) variants with exfoliation syndrome (XFS), exfoliation glaucoma (XFG), and primary open angle glaucoma (POAG) in a Turkish population. METHODS: Two LOXL1 single nucleotide polymorphisms (SNPs), rs1048661 (R141L) and rs3825942 (G153D), were analyzed in 300 Turkish patients (100 patients with XFS, 100 patients with XFG, 100 patients with POAG) and 100 control subjects. RESULTS: The T allele of rs1048661 was underrepresented in patients with XFS (odds ratio [OR]=0.334, 95% confidence interval [CI]: 0.198-0.564, p=2.54 × 10(-5)) and XFG (OR=0.366, 95% CI: 0.219-0.611, p=8.56 × 10(-5)) compared to the control subjects. None of the patients with XFS or XFG had the A allele of rs3825942, whereas 16% of the control subjects had that variant (OR=0.025, 95% CI: 0.003-0.188, p=3.69×10(-9)). No association was observed between the SNPs studied and POAG. By using logistic regression analysis, the effect of rs1048661 remained significant (p=8.45 × 10(-8)) after controlling for the effect of rs3825942, whereas rs3825942 was not significant with conditioning on rs1048661. Female gender was protective against the disease controlling with the effect of the two SNPs (OR=0.527, 95% CI: 0.358-0.776, p=0.001). CONCLUSIONS: The findings of the current study indicate that in a logistic regression analysis model the T allele of rs1048661 is the most important risk-modifying factor for the development of XFS and XFG. Our results also confirm in a Turkish population the findings of previous reports describing the association between LOXL1 polymorphisms and XFS/XFG but not with POAG. The allele and genotype distribution in this cohort appear to be similar to those of Caucasians.