Trypan blue as a surgical adjunct in pediatric cataract surgery.

PURPOSE: To study the effect of trypan blue on lens capsule elasticity and ease of completing a continuous curvilinear capsulorhexis (CCC) in a sheep lens model and to subsequently observe the effects of trypan blue in the surgical setting of 3 pediatric patients. SETTING: State University of New York, Downstate Medical Center, Brooklyn, New York, USA. DESIGN: Prospective case series. METHODS: Twenty-four lenses were excised from fresh sheep globes. Twelve lenses were immersed in trypan blue for 2.5 minutes, and 12 lenses were immersed in a balanced salt solution for 2.5 minutes. Ease of completion of CCC was graded, and intralenticular pressure was quantified. A pediatric cataract surgeon used trypan blue to stain the lens capsules of 3 children during cataract surgery. The surgeon noted the effects of trypan blue on capsule elasticity and on the ease of completion of the CCC. RESULTS: Lenses immersed in trypan blue had a mean score of 2.58 in ease of completion of capsulorhexis compared with the control group (1.5) (P = .031). Capsulorhexis was successfully completed in 91.7% of trypan blue cases compared with 58.3% of controls. Immersion in trypan blue decreased the intralenticular pressure by a mean of 4.5 mm Hg (P = .025). Successful capsulorhexis was completed in the 3 pediatric cases. CONCLUSION: Trypan blue improved the success rate of CCC completion in the sheep lens by decreasing lens capsule elasticity. FINANCIAL DISCLOSURE: None of the authors has a financial or proprietary interest in any material or method mentioned.

Human Platelet Lysate as a Replacement for Fetal Bovine Serum in Limbal Stem Cell Therapy.

PURPOSE: To evaluate the use of human platelet lysate (HPL) as an alternative supplement for limbal explant culture. METHODS: Culture media were prepared using either 10% pooled HPL (PHPL), single donor HPL, or fetal bovine serum (FBS). Limbal tissues, obtained from the Minnesota Lions Eye Bank, were cultured in each medium on plastic plates or on denuded amniotic membrane (AM). Immunofluorescence staining was performed for ABCG2, tumor protein p63α, and cytokeratin 3 (K3). Quantitative reverse transcriptase polymerase chain reaction (qRT-PCR) was used to evaluate the expression of ABCG2 and p63. Limbal explants grown in each medium were labeled with bromodeoxyuridine (BrdU) to assess the proliferative capacity in each medium. Concentration of growth factors including epidermal growth factor (EGF), vascular endothelial growth factor (VEGF), transforming growth factor-ß (TGF-ß), and platelet derived growth factor (PDGF) in HPL and PHPL was compared to that in human serum (HS). RESULTS: Immunofluorescence staining on AM showed prominent expression of ABCG2, p63α but sparse expression of K3 in HPL and PHPL supplemented medium. Real time-PCR showed 1.7 fold higher expression of ABCG2 in PHPL supplemented medium (p = 0.03), and similar expression of p63 in HPL and PHPL supplemented medium compared to FBS medium. The proliferation assay showed that LSCs retained their proliferative potential in HPL supplemented medium. Higher concentration of growth factors were found in HPL, compared to HS. CONCLUSIONS: Human platelet lysate has higher concentration of grown factors and is effective in maintaining growth and stem cell phenotype of corneal limbal explant cultures.

Iritis, glaucoma and corneal decompensation associated with BrightOcular cosmetic iris implant.

PURPOSE: NewColorIris cosmetic iris implants have a record of high ocular morbidity and are no longer in use. Newer generation of iris implants, BrightOcular, have patented posterior grooves in order to decrease iris touch and facilitate aqueous flow around the implant. However, little is known about their safety despite their implantations in 10 countries. METHODS: Collaborative case series of patients who had bilateral implantation of cosmetic iris implants solely for cosmetic reasons. RESULTS: 12 cases were collected being distributed as Caucasian (10) and Asian (2), women (11) and man (1) and with a mean age of 32 years. Ocular manifestations were present in 11 subjects and included anterior uveitis (10 of 12; 83.3%), glaucoma (7 of 12; 58.3%) and corneal decompensation (6 of 12; 50%). Visual acuity was normal in seven, decreased in five with two having visual recovery following explantation of the implant. Glaucoma could not be controlled medically in two patients. CONCLUSIONS: Cosmetic iris implants carry the risk of ocular damage when implanted in the anterior chamber of normal phakic eyes.

Rare Anterior Segment Retinoblastoma Masquerading as Corneal Endotheliitis.

We present a unique case involving a 6-year-old female with a unilateral corneal endotheliitis-like finding, who was ultimately found to have a form of anterior diffuse infiltrating retinoblastoma with no evidence of retinal involvement. The patient's presumed endotheliitis was initially treated with topical dexamethasone and oral acyclovir without improvement. She then underwent multiple fine-needle aspirations of anterior chamber fluid, which were negative for abnormal findings of viral polymerase chain reaction, viral cultures, and flow cytometry. Months after initial presentation, an anterior chamber angle mass developed and a biopsy identified retinoblastoma cells. The patient underwent plaque radiotherapy of the cornea and systemic chemotherapy. The patient regained good vision and is tumor-free at 13 months. Anterior inflammation is a rare form of masquerade syndrome associated with retinoblastoma; however, it tends to be associated with diffuse posterior segment retinoblastoma when it does occur. Diffuse anterior retinoblastoma is a rare form of retinoblastoma with no apparent focus in the retina. Ultimately, our patient developed an anterior chamber angle lesion, which was biopsied and proven to be retinoblastoma. Unusual corneal endotheliitis-like findings in children that are not responsive to conventional treatment should raise the clinician's suspicion of malignancy, even when no retinal lesion is detected.

Boston Keratoprosthesis: Outcomes and Complications: A Report by the American Academy of Ophthalmology.

OBJECTIVE: To review the published literature on safety and outcomes of the Boston type I keratoprosthesis (BI-KPro) for the surgical treatment of corneal opacification not amenable to human cadaveric corneal transplantation. METHODS: Searches of peer-reviewed literature were conducted in PubMed and the Cochrane Library in December 2012, July 2013, and January 2014 without date restrictions. The searches were limited to studies published in English and yielded 587 citations. The abstracts of these articles were reviewed, 48 articles were selected for possible clinical relevance, and 22 were determined to be relevant for the assessment objectives. Nine studies were rated as level II evidence and 13 studies were rated as level III evidence. Excluded were level III evidence, case reports, review articles, letters, editorials, and case series with fewer than 25 eyes. RESULTS: In 9 articles, a best-corrected Snellen visual acuity (BCSVA) of 20/200 or better occurred in 45% to 89% of eyes. Five articles described a BCSVA of 20/50 or better in 43% to 69% of eyes, and 4 articles found a BCSVA of 20/40 or better in 11% to 39% of eyes. Retention rates of the BI-KPro ranged from 65% to 100%. Reasons for loss of vision after BI-KPro implantation most commonly included corneal melts resulting from exposure keratopathy, endophthalmitis, and infectious keratitis or corneal ulceration. The 2 most common complications after surgery were retroprosthetic membrane formation (range, 1.0%-65.0%; mean ± standard deviation [SD], 30.0±19.0%) and elevated intraocular pressure (range, 2.4%-64.0%; mean ± SD, 27.5±18.1%). The 2 most common posterior segment complications were endophthalmitis (range, 0%-12.5%; mean ± SD, 4.6±4.6%) and vitritis (range, 0%-14.5%; mean ± SD, 5.6±4.7%). CONCLUSIONS: The reviewed articles on BI-KPro use suggest that the device improves vision in cases of severe corneal opacification that were not amenable to corneal transplantation using human cadaveric keratoplasty techniques. A number of severe anterior and posterior segment complications can develop as follow-up continues, making ongoing close observation paramount for patients undergoing this surgery. These complications include infection, device extrusion, and permanent vision loss.

Delayed presentation of retained nuclear fragment following phacoemulsification cataract extraction.

UNLABELLED: An 87-year-old woman presented 11 months after routine phacoemulsification cataract extraction and posterior chamber intraocular lens implantation in her left eye complaining of the abrupt onset of redness and decreased vision in that eye. Examination revealed a mild anterior chamber reaction and significant corneal edema. The eye was minimally responsive to topical steroid therapy, and initial serial slitlamp examinations with gonioscopy were unrevealing. After multiple head-positioning maneuvers were performed, a retained nuclear fragment was uncovered. The nuclear fragment was aspirated and liquefied by the phacoemulsification device in the anterior chamber. A retained nuclear fragment with an intact posterior capsule is a recognized cause of inflammation in the immediate postoperative presentation. Delayed presentation of symptoms is rare and presumably secondary to sequestration of the fragment behind the iris. We present a case and a review of the literature regarding sequestered retained nuclear fragments following what is initially thought to be uneventful cataract extraction. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Options and adjuvants in surgery for pterygium: a report by the American Academy of Ophthalmology.

OBJECTIVE: To assess the outcomes and safety of current surgical options and adjuvants in the treatment of primary and recurrent pterygium. METHODS: Literature searches of the PubMed and the Cochrane Library databases were last conducted in January 2011 using keywords and were restricted to randomized controlled trials reporting on surgical intervention for pterygium. The searches were limited to articles published in English and yielded 120 citations. Citation abstracts, and if necessary the full text, were reviewed to identify randomized controlled trials that reported recurrence as an outcome measure and had a mean follow-up of at least 6 months. Fifty-one studies comparing bare sclera excision, conjunctival or limbal autograft, intraoperative mitomycin C, postoperative mitomycin C, and amniotic membrane transplantation for primary and recurrent pterygia fit these inclusion criteria. RESULTS: Four studies demonstrated that the conjunctival or limbal autograft procedure is more efficacious than amniotic membrane placement. Use of conjunctival or limbal autografts or mitomycin C during or after pterygium excision reduced recurrence compared with bare sclera excision alone in most studies of primary or recurrent pterygium. The outcomes of conjunctival or limbal autograft were similar to outcomes for intraoperative mitomycin C in the few studies that directly compared the 2 techniques. There is evidence that increased concentration and duration of exposure to intraoperative mitomycin C is associated with increased efficacy. Of the adjuvants studied, only mitomycin C was associated with vision-threatening complications, including scleral thinning, ulceration, and delayed conjunctival epithelialization; there is some evidence of increasing complications with increased concentration and duration of exposure. There is conflicting evidence as to whether increasing age is protective against recurrence, but the morphologic features of the pterygium were shown to affect the recurrence rate. CONCLUSIONS: Evidence indicates that bare sclera excision of pterygium results in a significantly higher recurrence rate than excision accompanied by use of certain adjuvants. Conjunctival or limbal autograft was superior to amniotic membrane graft surgery in reducing the rate of pterygium recurrence. Among other adjuvants, there is evidence that mitomycin C and conjunctival or limbal autografts reduce the recurrence rate after surgical excision of a pterygium. Furthermore, the data indicate that using a combination of conjunctival or limbal autograft with mitomycin C further reduces the recurrence rate after pterygium excision compared with conjunctival or limbal autograft or mitomycin C alone. Additional studies are necessary to determine the long-term effects, optimal route of administration, and dose and duration of treatment for mitomycin C. Factors such as availability of resources, primary or recurrent status of pterygium, age of patient, and surgeon or patient preference may influence the surgeon's choice of adjuvant because there are insufficient data to recommend a specific adjuvant as superior. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Deep anterior lamellar keratoplasty as an alternative to penetrating keratoplasty a report by the american academy of ophthalmology.

OBJECTIVE: To review the published literature on deep anterior lamellar keratoplasty (DALK) to compare DALK with penetrating keratoplasty (PK) for the outcomes of best spectacle-corrected visual acuity (BSCVA), refractive error, immune graft rejection, and graft survival. METHODS: Searches of the peer-reviewed literature were conducted in the PubMed and the Cochrane Library databases. The searches were limited to citations starting in 1997, and the most recent search was in May 2009. The searches yielded 1024 citations in English-language journals. The abstracts of these articles were reviewed, and 162 articles were selected for possible clinical relevance, of which 55 were determined to be relevant to the assessment objective. RESULTS: Eleven DALK/PK comparative studies (level II and level III evidence) were identified that compared the results of DALK and PK procedures directly; they included 481 DALK eyes and 501 PK eyes. Of those studies reporting vision and refractive data, there was no significant difference in BSCVA between the 2 groups in 9 of the studies. There was no significant difference in spheroequivalent refraction in 6 of the studies, nor was there a significant difference in postoperative astigmatism in 9 of the studies, although the range of astigmatism was often large for both groups. Endothelial cell density (ECD) stabilized within 6 months after surgery in DALK eyes. Endothelial cell density values were higher in the DALK groups in all studies at study completion, and, in general, the ECD differences between DALK and PK groups were significant at all time points at 6 months or longer after surgery for all of the studies reporting data. CONCLUSIONS: On the basis of level II evidence in 1 study and level III evidence in 10 studies, DALK is equivalent to PK for the outcome measure of BSCVA, particularly if the surgical technique yields minimal residual host stromal thickness. There is no advantage to DALK for refractive error outcomes. Although improved graft survival in DALK has yet to be demonstrated, postoperative data indicate that DALK is superior to PK for preservation of ECD. Endothelial immune graft rejection cannot occur after DALK, which may simplify long-term management of DALK eyes compared with PK eyes. As an extraocular procedure, DALK has important theoretic safety advantages, and it is a good option for visual rehabilitation of corneal disease in patients whose endothelium is not compromised.

Descemet's stripping endothelial keratoplasty: safety and outcomes: a report by the American Academy of Ophthalmology.

OBJECTIVE: To review the published literature on safety and outcomes of Descemet's stripping endothelial keratoplasty (DSEK) for the surgical treatment of endothelial diseases of the cornea. DESIGN: Peer-reviewed literature searches were conducted in PubMed and the Cochrane Library with the most recent search in February 2009. The searches yielded 2118 citations in English-language journals. The abstracts of these articles were reviewed and 131 articles were selected for possible clinical relevance, of which 34 were determined to be relevant to the assessment objectives. RESULTS: The most common complications from DSEK among reviewed reports included posterior graft dislocations (mean, 14%; range, 0%-82%), followed by endothelial graft rejection (mean, 10%; range, 0%-45%), primary graft failure (mean, 5%; range, 0%-29%), and iatrogenic glaucoma (mean, 3%; range, 0%-15%). Average endothelial cell loss as measured by specular microscopy ranged from 25% to 54%, with an average cell loss of 37% at 6 months, and from 24% to 61%, with an average cell loss of 42% at 12 months. The average best-corrected Snellen visual acuity (mean, 9 months; range, 3-21 months) ranged from 20/34 to 20/66. A review of postoperative refractive results found induced hyperopia ranging from 0.7 to 1.5 diopters (D; mean, 1.1 D), with minimal induced astigmatism ranging from -0.4 to 0.6 D and a mean refractive shift of 0.11 D. A review of graft survival found that clear grafts at 1 year ranged from 55% to 100% (mean, 94%). CONCLUSIONS: The evidence reviewed is supportive of DSEK being a safe and effective treatment for endothelial diseases of the cornea. In terms of surgical risks, complication rates, graft survival (clarity), visual acuity, and endothelial cell loss, DSEK appears similar to penetrating keratoplasty (PK). It seems to be superior to PK in terms of earlier visual recovery, refractive stability, postoperative refractive outcomes, wound and suture-related complications, and intraoperative and late suprachoroidal hemorrhage risk. The most common complications of DSEK do not appear to be detrimental to the ultimate vision recovery in most cases. Long-term endothelial cell survival and the risk of late endothelial rejection are beyond the scope of this assessment. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Uveitis-glaucoma-hyphema syndrome and corneal decompensation in association with cosmetic iris implants.

PURPOSE: To report a case and management of uveitis-glaucoma-hyphema (UGH) syndrome and corneal decompensation associated with cosmetic iris implants. DESIGN: Interventional case report. SETTINGS: Department of Ophthalmology, University of Minnesota School of Medicine. PATIENTS: A 29-year-old man presented with bilateral redness, severe pain, photophobia, and reduction in visual acuity. Examination revealed intraocular pressure (IOP) of 38 mm Hg and 40 mm Hg right and left eye respectively, bilateral conjunctival injection 3+, epithelial corneal edema, microhyphema, cells 3+ to 4+ and flare 2+, bilateral cosmetic iris implants, and surgical peripheral iridectomies. The patient was diagnosed with UGH syndrome and corneal decompensation associated with cosmetic iris implants. INTERVENTION: Immediate medical management of inflammation and elevated IOP, anterior segment imaging, specular microscopy, Humphrey 24-2 visual field (VF) testing; following failed conservative management, combined trabeculectomy and removal of the iris implants. MAIN OUTCOME MEASURES: Anterior chamber inflammation and microhyphema, IOP, and corneal edema. RESULTS: Anterior segment imaging demonstrated bilateral implant-iris apposition and implant-angle structures apposition. Specular microscopy demonstrated a significant reduction of the number of endothelial cells. VF test demonstrated a right superior arcuate scotoma and a normal left VF. Following surgical treatment IOP normalized and inflammation and microhyphema subsided. However, mild corneal edema persisted. CONCLUSION: Cosmetic iris implantation may lead to UGH syndrome and corneal decompensation. Therefore, its use should be reserved for patients with significant medical indications, and avoided in patients with intact natural iridies, until more short-term and long-term safety data are available.

Corneal collagen cross-linking: a confocal, electron, and light microscopy study of eye bank corneas.

PURPOSE: The purpose of this study was to evaluate morphological changes induced by corneal collagen cross-linking in a human ex vivo cornea, using confocal, electron, and light microscopy. METHODS: The central epithelium was partially removed from ex vivo human corneal buttons. Riboflavin 0.1% solution was applied before ultraviolet A light treatment and then for every 2 minutes for 30 minutes while the corneas were exposed to ultraviolet A light at a wavelength of 370 nm and intensity of 3 mW/cm(2). Each cornea was evaluated using confocal, electron, and light microscopy. RESULTS: Confocal microscopy demonstrated normal-appearing corneas on their initial pretreatment examination, with reduced stromal detail. After treatment, a superficial layer of highly reflective spherical structures (4-10 microm) was observed. Many of these hyperreflective structures appeared up to a depth of 300 microm. The remainder of the corneal stroma and endothelium appeared normal. Electron microscopy showed keratocyte apoptotic changes to a depth of 300 microm. No observable pathologic changes were seen on histology. CONCLUSIONS: Based on clinical studies, corneal cross-linking is a promising treatment that appears to be safe and to halt ectatic corneal disease progression. Initial European studies used animal models to extrapolate human protocols. In conjunction with clinical studies, we believe that human ex vivo corneal studies provide a means to evaluate the structural and morphological changes associated with this procedure, within human corneas, in a manner that cannot be accomplished in vivo.

Epithelial downgrowth after Descemet-stripping automated endothelial keratoplasty.

A 66-year-old man presented with decreased vision and corneal edema after 2 failed Descemet-stripping automated endothelial keratoplasty (DSAEK) graft procedures in the left eye. An uneventful third DSAEK procedure combined with anterior vitrectomy through the previous limbal wound was performed. Postoperative recovery was uneventful. Histopathology of the excised failed graft revealed conjunctival epithelium on the posterior surface of the tissue. At 1 year, the endothelial cell count was 1997 cells/mm(2) and the uncorrected visual acuity was 20/20(-2). At 18 months, the graft remained clear with no signs of epithelial downgrowth. Clinicians should be aware that epithelial downgrowth can occur following DSAEK surgery. Fortunately, excision of the prior DSAEK graft with removal of the active epithelial membrane appears to have been a successful treatment in this patient.

Safety of overnight orthokeratology for myopia: a report by the American Academy of Ophthalmology.

OBJECTIVE: To review the published literature to evaluate the safety of overnight orthokeratology (OOK) for the treatment of myopia. METHODS: Repeated searches of peer-reviewed literature were conducted in PubMed (limited to the English language) and the Cochrane Central Register of Controlled Trials (no language limitations) for 2005, 2006, and 2007. The searches yielded 495 citations. The panel reviewed the abstracts of these articles and selected 79 articles of possible clinical relevance for review. Of these 79 full-text articles, 75 were determined to be relevant to the assessment objective. RESULTS: No studies were rated as having level I evidence. Two premarket applications to the Food and Drug Administration were rated as having level II evidence. There were 2 studies rated as having level II evidence. The main source of reports of adverse events associated with OOK was 38 case reports or noncomparative case series (level III evidence). CONCLUSIONS: The prevalence and incidence of complications associated with OOK have not been determined. Complications, including more than 100 cases of infectious keratitis resulting from gram-positive and gram-negative bacteria and Acanthamoeba, have been described in case reports and case series representing observations in undefined populations of OOK users. Data collection was nonstandard. Risk factors for various complications cannot be determined. Because OOK puts patients at risk for vision-threatening complications they may not encounter otherwise, sufficiently large well-designed cohort or randomized controlled studies are needed to provide a more reliable measure of the risks of treatment and to identify risk factors for complications. Overnight orthokeratology for slowing the progression of myopia in children also needs well-designed and properly conducted controlled trials to investigate efficacy. Because of variations in orthokeratology practice, a wide margin of safety should be built into OOK regimens. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.