[Current possibilities for the diagnosis and treatment of pterygium]. / Sovremennye vozmozhnosti diagnostiki i lecheniya pterigiuma.

Pterygium is a common inflammatory-proliferative disease characterized by the invasion of degeneratively altered fibrovascular tissue into the cornea. This literature review analyzes the etiological factors and pathogenetic concepts of its development, describes modern methods of diagnostics and surgical treatment of pterygium, and pays particular attention to the assessment of structural and functional changes in the cornea occurring during the growth of pterygium and after its excision.

[Correction of refractive disorders after surgical treatment of recurrent pterygium (case study)]. / Korrektsiya refraktsionnykh narushenii posle khirurgicheskogo lecheniya retsidiviruyushchego pterigiuma (klinicheskoe nablyudenie).

Lamellar keratoplasty is the most effective and safe method of surgical treatment of recurrent pterygium, providing restoration of the corneal frame and optical properties and a high anti-relapse effect due to the barrier properties of the lamellar graft. However, potential postoperative changes in the regularity of the anterior and posterior surfaces of the cornea (especially in case of advanced stage of fibrovascular tissue growth) do not always allow achieving high functional results of treatment. The article presents a clinical case that demonstrates the effectiveness and safety of excimer laser correction of refractive disorders after surgical treatment of pterygium.

[Epithelial ingrowth after anterior lamellar keratoplasty (clinical observation)]. / Vrastanie epiteliya posle perednei posloinoi keratoplastiki (klinicheskoe nablyudenie).

Epithelial ingrowth (EI) is a rarely occurring complication of surgeries on the anterior eye segment characterized by migration and proliferation of epithelial cells along the wound tract or into the anterior chamber. Several decades ago, EI often led to severe complications, including enucleation. Modern treatment methods allow not only removing the pathological focus of EI, but also minimizing the risk of its reoccurrence. This article presents a clinical case of EI after anterior lamellar keratoplasty involving formation of implant bed under the pathological focus without cutting open the interface zone. The technique helps minimize dissemination of epithelial cells in the area of the lesion. To prevent growth reoccurrence, the method was supplemented with application of a cytostatic agent. The treatment resulted in stable remission throughout the follow-up period (26 months).

[Salzmann nodular degeneration: pathogenesis, clinical characteristics and treatment]. / Uzelkovaya degeneratsiya Zal'tsmana: osobennosti patogeneza, klinicheskoi kartiny i lecheniya.

Salzmann nodular degeneration (SND) is a rare non-inflammatory disease observed primarily in middle-aged women. The disease generally occurs in patients with chronic inflammation of the anterior ocular surface. Its etiopathogenesis remains poorly investigated. This literature review describes clinical manifestations, risk factors and diagnostic methods, evaluates the effectiveness of different therapeutic and surgical treatment methods. Understanding of the pathogenetic mechanisms, precise diagnosis and identification of the risk factors can help clinical physicians make the optimal choice of treatment strategy and achieve the best clinical outcomes.

[Modern capabilities of ophthalmic tonometry in pathologically altered corneas]. / Sovremennye vozmozhnosti oftal'motonometrii pri patologicheskikh izmeneniyakh rogovitsy.

Changes in intraocular pressure have great influence on the course of various processes in ocular tissues. Presently, the scientific discussion has returned to the theoretical issues of tonometry and the creation of models that would allow assessing the influence of various ocular parameters on IOP values. Some of the modern tonometers (Icare, Tono-Pen) are convenient and effective when measuring IOP in eyes with damaged, uneven or edematous cornea. It is necessary to analyze the results of ophthalmic tonometry by modern methods in accordance with the data of direct intracameral manometry in pathological conditions of the cornea and after keratoplasty.

[Antiangiogenic therapy in the surgical treatment of pterygium]. / Antiangiogennaya terapiya v khirurgicheskom lechenii pterigiuma.

PURPOSE: To evaluate the effectiveness and safety of adjuvant anti-VEGF therapy in the surgical treatment of pterygium, and to determine the indications for its use. MATERIAL AND METHODS: The study included 67 patients (69 eyes) with grade II-IV pterygium. Patients age was 58.8±12.6 years on average. Best corrected visual acuity (BCVA) varied between 0.01 and 1.0 (0.77±0.24). The patients were divided into 3 groups. The first group included 19 patients (19 eyes) with grade II-III pterygium who underwent «bare sclera¼ surgery and used aflibercept as adjuvant therapy. The second group included 21 patients (21 eyes) with grade II-IV pterygium who underwent auto conjunctival grafting surgery with no adjuvant therapy. The third group included 27 patients (29 eyes) with grade II-IV pterygium who had it removed in combination with single-time peripheral lamellar keratoplasty (PLK) and underwent adjuvant aflibercept therapy. RESULTS: Among patients who underwent pterygium excision with adjuvant antiangiogenic therapy there were 5 cases (26%) of relapse during the observation period (23.38±8.96 months), among patients after pterygium excision with auto conjunctival plastic surgery - also 5 cases (24%) of relapse, and among patients who underwent LKP combined with anti-VEGF therapy there was only 1 case (3%) of relapse. Astigmatism has decreased by 0.24±0.5 (p=0.052) in the first group, by 1.21±1.0 (p<0.05) in the second group, and by 1.64±1.54 (p<0.05) in the third group compared with pre-surgical values, thus increasing average BCVA in all 3 patient groups by 0.1±0.13, 0.07±0.11 and 0.15±0.15, respectively. CONCLUSION: The use of anti-VEGF agents as adjuvant therapy in the surgical treatment of pterygium is a safe method of reducing postoperative inflammation, fibrovascular proliferation and, subsequently, the amount of relapses.

[Antiangiogenic therapy in high-risk keratoplasty]. / Antiangiogennaya terapiya pri keratoplastike vysokogo riska.

PURPOSE: To analyze the effectiveness and safety of VEGF inhibitor used to improve keratoconus transplant survival in patients with corneal neovascularization as stand-alone and in combination with laser coagulation of ingrowing vessels before keratoplasty. MATERIAL AND METHODS: The study included 56 patients (56 eyes) with corneal opacifications of various etiology complicated by corneal neovascularization (CNV). The patients were divided into three groups. The 1st group included 27 patients with diffuse CNV who were undergoing an antiangiogenic therapy using anti-VEGF drug, the 2nd group - 14 patients with stem cell CNV who underwent laser coagulation of major corneal vessels combined with subconjunctival administration of drug before keratoplasty; the control group consisted of 15 patients with mixed type CNV who were undergoing conventional treatment without antiangiogenic therapy. RESULTS: During the follow-up (24.5±4.84 months, 4 to 25 months), transplant rejection reaction was recorded in 7 (23%) patients of the 1st group, 5 (35%) patients of the 2nd group and 9 (60%) patients of the control group. CONCLUSION: Subconjunctival administration of Aflibercept as a stand-alone measure and in combination with laser coagulation of ingrowing vessels may increase the chances of transparent transplant acceptance in high-risk keratoplasty.

[Morphological changes in the cornea of patients with recurrent corneal erosion after diamond burr polishing of Bowman's membrane]. / Morfologicheskie izmeneniia rogovitsy pri sindrome retsidiviruiushchei érozii posle shlifovki boumenovoi membrany almaznym borom.

PURPOSE: To evaluate morphological changes in the cornea of patients with recurrent corneal erosion (RCE) using laser confocal microscopy before and after abrasive polishing of Bowman's membrane with a diamond burr (APBMDB). MATERIAL AND METHODS: The study included 17 patients (20 eyes) with established RCE diagnosis; they underwent laser confocal microscopy on HRT III device with Rostock Cornea module (Heidelberg Engineering GmbH, Germany). Morphological analysis of epithelial cells, nerve fibers, stroma and corneal endothelium was conducted. After that, all patients underwent APBMDB. Patient examination was repeated after 1, 3, 6, and 12 months. RESULTS: Superficial epithelium was intact before treatment in almost all cases. Islets of hyper-reflective cells, drop-shaped arrangements and stripes characterizing abnormal basal membrane were found in basal epithelium layer. Activated keratocytes and anomalous extracellular matrix were observed in the anterior stroma. No changes could be found in the posterior stroma or endothelium. Subbasal nerve plexus had changes in the form of short and atypically formed corneal nerve fiber funiculi, reduced amount of long corneal nerve fiber funiculi, as well as their tendency for forming closed round shapes. Increase in the amount of Langerhans cells was observed. One month after the procedure, pathological changes in the epithelium and basal membrane were absent, reduction in the amount of Langerhans cells and activated keratocytes was observed. Three months after the polishing, continued reduction of the amount of Langerhans cells was noted. Regeneration of nerves partially restored after 6 months; after 12 months, confocal microscopy results were comparable to healthy volunteers. CONCLUSION: Confocal laser microscopy of the cornea of patients with RCE showed presence of changes in basal epitheliocytes, basal membrane, anterior stroma and corneal nerve fibers, as well as positive dynamics of these changes after abrasive polishing of Bowman's membrane with a diamond burr.

[Polishing of Bowman's membrane with diamond burr in the treatment of recurrent corneal erosion syndrome]. / Abrazivnaia shlifovka boumenovoi membrany almaznym borom v lechenii retsidiviruiushchei érozii rogovitsy.

PURPOSE: To study the effectiveness of polishing Bowman's membrane with a diamond burr (DBPBM) in the treatment of recurrent corneal erosion syndrome (RCES). MATERIAL AND METHODS: The study included 22 patients (22 eyes) with RCES aged 20-56 years who underwent our original modification of DBPBM. All patients had keratotopography examined, endothelial cell density measured, and optical coherence tomography (OCT) of the cornea taken before and after the procedure. Additionally, conjunctival scraping, blood test for types I and II herpes (fluorescent antibody method) were performed before the surgery. Post-operative treatment included 1-2 weeks of anti-inflammatory and anti-bacterial steroid therapy, and 6 months of artificial tear Cationorm usage. RESULTS: Rehabilitation of all patients after the procedure went quickly, and no relapses were noted during the follow-up. Complete epithelialization of the area of surgical intervention under soft contact lens occurred over 2-3 days. Epithelial thickness was measured with OCT including epithelial mapping; after the surgery, it was almost even over the entire corneal surface. No complications such as induced post-operative refractive error or corneal haze were registered during the course of the study. Disruption of basal epithelial layer and epithelial basal membrane in the area of erosion relapse detected with scanning electron microscopy confirmed the need for their removal in the course of the surgery. CONCLUSION: Conservative treatment of RCES rarely yields results. Removal of inadequate epithelium and following DBPBM using our original method is a highly effective and accessible procedure for RCES treatment with low risk of complications and relapse.

[Peripheral lamellar keratoplasty in treatment of relapsing pterygium]. / Perifericheskaia posloinaia keratoplastika v lechenii retsidiviruiushchego pterigiuma.

PURPOSE: To evaluate the effectiveness and safety of peripheral lamellar keratoplasty (LKP) for treating relapsing pterygium. MATERIAL AND METHODS: The study was conducted in the period of 2007-2017 and included 84 patients (91 eyes) with stage II-IV relapsing pterygium. Best corrected visual acuity (BCVA) before the surgery was in average 0.65±0.28 (0.01 to 1.0). Astigmatism varied from 0.5 to 6.5 D (mean 3.41±2.06). All patients underwent pterygium removal surgery followed by LKP. The analyzed parameters included visual acuity, refraction error before and after the surgery, frequency of relapses and post-operative complications. RESULTS: The follow-up period was 4 months to 10 years (mean 30.9±25.4 months). BCVA after the surgery was 0.1-1.2 (mean 0.83±0.24), post-operative astigmatism - 0 to 3.5 D (1.08±0.62). BCVA has improved and remained stable in 86 (94.5%) out of 91 eyes, decrease of visual acuity was observed in 5 cases (5.5%). Frequent relapse of pterygium happened in 5 cases (5.5%), was non-progressing and required no surgical treatment. CONCLUSION: LKP is an effective and safe method of surgical treatment of relapsing pterygium that provides good optical, tectonic and anti-relapsing results thanks to barrier properties of the layered transplant.

[Pterygium: etiology, pathogenesis, treatment]. / Pterigium: étiologiia, patogenez, lechenie.

Pterygium is a degenerative condition characterized by fibrovascular outgrowth of conjunctiva over the cornea. Many theories exist that try to explain its pathogenesis. The current belief is that this disease is multifactorial with ultraviolet radiation being the most important trigger. Attention is also paid to such factors as tear film changes, cytokines and growth factors disbalance, immunologic disturbances, genetic mutations, and viral infections. Modern classifications consider the rate of fibrovascular growth, its progressive potential, and histological features. In the beginning pterygium is usually asymptomatic, however, dry eye manifestations may be present, such as burning, itching, and/or tearing. As the lesion grows toward the optical zone, visual acuity gets compromised, and thus, surgical treatment is required. Because of recurrences and repeated surgeries, the growth of the lesion may become more aggressive and cause irregular astigmatism. Comprehensive surgery of pterygium is aimed at not only removing the lesion, but also preventing recurrences. Advisable are modified bare sclera techniques with subsequent transposition of the conjunctival flap, conjunctival autotransplantation, amniotic membrane transplantation, and peripheral lamellar keratoplasty (in cases of significant ingrowth). In some cases, antirecurrent adjuvant therapy may be considered that involves the use of mitomycin C, 5-fluoruracil, and VEGF inhibitors. However, the search for the best treatment for pterygium, i.e. an easy to perform, cosmetically-friendly method associated with minimal risk of recurrences and/or complications, remains an interest of modern ophthalmology.

[Influence of endothelial graft thickness on postoperative visual acuity]. / Otsenka vliianiia tolshchiny éndotelial'nogo transplantata na posleoperatsionnuiu ostrotu zreniia.

AIM: to assess the influence of the endothelial graft thickness on postoperative visual acuity following modified endothelial keratoplasty (UTDSAEK). MATERIAL AND METHODS: The study included 49 patients with pseudophakic bullous keratopathy and no concomitant disorders of either the retina or optic nerve. Ultrathin Descemet's stripping automated endothelial keratoplasty (UTDSAEK) was performed in all cases. Corneal graft thickness was measured 1 year after UTDSAEK by means of optical coherence tomography. Postoperative visual acuity values were compared in patients with the endothelial graft thickness from 51 to 98 microns (27 eyes) and those with the endothelial graft thickness from 102 to 121 microns (22 eyes). The dynamics of the graft thickness change after surgery was also assessed. RESULTS: The thickness of the graft gets reduced by an average of 21% over the first 2-3 weeks after UTDSAEK and by approximately 5% over 2 more months. For the next few years it remains relatively stable (the maximum follow-up period was 5 years). The study showed no statistically significant difference in visual acuity between two groups of patients with the endothelial graft thickness of less than and greater than 100 microns (p=0.7). CONCLUSION: The thickness of the endothelial graft for UTDSAEK has no statistically significant effect on postoperative visual acuity. The optimal thickness of the graft being cut out lies in the range from 100 to 150 microns. Such grafts adapt well to the posterior surface of the recipient cornea with no significant changes to its topography. Moreover, thicker grafts are easier manipulated before insertion into the anterior chamber and are associated with a lower risk of perforation during acquisition as compared to grafts of under 100 microns.

[Fuchs endothelial corneal dystrophy]. / Éndotelial'naia distrofiia rogovitsy Fuksa.

Fuchs endothelial dystrophy is a severe disease characterized by slowly progressing bilateral asymmetric corneal edema usually seen in elderly patients. The primary purpose of treatment is to minimize edema-related symptoms, such as ocular discomfort and visual acuity loss. Conservative therapy is symptomatic and has a short-term positive effect that does not lead to full functional rehabilitation of the patient, while endothelial keratoplasty is pathogenetically oriented. Intentional replacement of pathologically altered corneal layers has several advantages: preservation of corneal architectonics, rapid recovery of visual function, 'closed eye' surgery with corneal tunnel approach, and independence from expensive equipment. However, principle indications and contraindications for various modifications of endothelial keratoplasty in the presence of comorbidity are still to be defined. Further improvement of the methods and their broader implementation into clinical practice are the most pressing and promising issues of corneal transplantation.

[Hypothesis of immune privilege of the cornea and pathophysiology of graft rejection]. / Gipoteza immunnoi privilegii rogovitsy i patofiziologiia ottorzheniia keratotransplantata.

Transplantation of donated cornea is a radical and pathogenetically oriented measure of rehabilitation for patients with corneal blindness. Unlike other transplantation surgeries, keratoplasty is usually done without tissue typing and systemic immunosuppression. Even so, in the absence of risk factors, grafts can remain clear in as many as 90% of cases. The phenomenon is explained by immune privilege of the cornea. The hypothesis of immune privilege comprises several interrelated mechanisms that ensure long-lasting transparency of the graft. These include transfer limits of immunogenic stimuli to peripheral lymphoid tissues, deviation of the immune response, and neutralization of immune effector elements within the host-graft interface by immunosuppressive ocular environment. A change in any of the said components leads to loss of the immune-privilege status of the cornea, thus, significantly increasing the risk of graft rejection. We know several stages of the response activation cascade in graft rejection that can be influenced therapeutically, namely, antigen absorption, processing, and presentation as well as T-cell expansion and cellular inflow to the eye. The first two stages take place in the eye itself and are susceptible to instillation drugs and gene therapy. New highly selective medications aimed at specific signals from the immune cells and their pathways may be able to help restore the immune privilege of the cornea and improve the results of optical and reconstructive surgeries in high-risk patients.

[Risk factors, clinical presentations, prevention, and treatment of corneal graft rejection]. / Faktory riska, klinicheskie proiavleniia, metody profilaktiki i lecheniia reaktsii ottorzheniia transplantata rogovitsy.

Corneal transplantation is the most common and successful type of allotransplantation surgery. Post-transplant immune response in keratoplasty is less pronounced than that in other transplantation procedures, which is accounted for by anatomical features of the cornea and, also, its low antigenic potential and active immunosuppression. However, the immune privilege of the cornea can be violated by neovascularization, inflammation, or trauma. Patients who require keratoplasty to restore their sight and whose immune privilege is disturbed, fall into a high-risk group and are likely to demonstrate tissue incompatibility and non-transparent engraftment. Two approaches exist as to how graft rejection can be prevented. One of them involves induction of donor-specific tolerance, the other - non-specific suppression of the recipient's immune response. To avoid tissue incompatibility, measures can be taken to restore the immune privilege of the cornea as well as to induce antigen-specific tolerance, which is considered a promising, thought yet experimental, area of modern transplantology. In clinical practice, one pays most attention to improvement of non-specific immune suppression methods based on interfering in the metabolism of immunocompetent cells. Thus, timely prescriptions and proper immunosuppressive tactics with account to possible risk factors determine the outcome in high-risk patients undergoing corneal transplantation surgery.

[Combined surgical treatment for bullous keratopathy with concomitant uncompensated glaucoma].

The article discusses a clinical case of combined surgical treatment for painful bullous keratopathy in an eye with uncompensated far-advanced glaucoma. Ex-PRESS Glaucoma Filtration Device was used for anterior chamber drainage. The procedure was supplemented by amniotic membrane implantation under the scleral flap, microdiathermocoagulation of large corneal epithelial bullae, and epikeratoplasty.

[Evaluation of corneal biomechanics before and after up-to-date keratoplasty in patients with bullous keratopathy]. / Otsenka biomekhanicheskikh svoistv rogovitsy do i posle sovremennykh modifikatsii keratoplastiki u bol'nykh s bulleznoi keratopatiei.

UNLABELLED: Aim - to study biomechanical properties of the cornea in patients with bullous keratopathy before and after keratoplasty. MATERIAL AND METHODS: Ocular response analyzer (ORA, Reichert) indices were studied in 37 patients (37 eyes) with bullous keratopathy before and after surgery - in 1, 2, and 6 months and then in 1, 2, 3, and 5 years. The following keratoplasty modifications were performed: ultrathin Descemet's stripping automated endothelial keratoplasty (UTDSAEK) - in 17 cases, microkeratome-assisted posterior keratoplasty (MAPK) - in 13 cases, half top-hat penetrating keratoplasty (HTH PK) - in 7 cases. RESULTS: Corneal hysteresis (CH) and corneal resistance factor (CRF) values were significantly decreased in non-operated bullous keratopathy eyes as compared to healthy ones (p<0.05). By the 6-month follow-up these parameters have been found to be partially recovered and stabilized in all groups, however, still lower than normal (p<0.05). Differences between the groups were never statistically reliable, not at any time after surgery. Moreover, in eyes with bullous keratopathy, the mean corneal-compensated intraocular pressure (IOPcc) exceeded the mean Goldman-related IOP (IOPg) by 2.4 mmHg. One month after keratoplasty the difference between IOPcc and IOPg was 2.7, 4.3, and 3.6 mmHg in the MAPK, UTDSAEK, and HTH PK group, respectively; in 6 months - 2.6; 2.4 and 3.6 mmHg, respectively (p<0.05). In the fellow healthy eyes the two IOP measurements were not statistically different. CONCLUSION: Chronic edema of the cornea results in alteration of its viscoelastic properties. It has been shown that CH and CRF values decrease significantly in the eye involved as compared to the fellow healthy eye. After keratoplasty, regardless of the exact modification, these parameters partially recover, but remain lower than normal for at least 5 years as it was in our study. Neither before the surgery (when the cornea is chronically swollen), nor after, does corneal thickness correlate with its biomechanical indices. Postoperative reduction in corneal rigidity in eyes with bullous keratopathy may be confusing and lead to underestimation of the true level of IOP, thus, causing delays in diagnosis of concomitant glaucoma.

[Modern endothelial keratoplasty-based options for visual rehabilitation of patients with bullous keratopathy and concomitant glaucoma].

PURPOSE: To develop endothelial keratoplasty-based surgical treatment and management policy for patients with bullous keratopathy complicated by glaucoma. MATERIAL AND METHODS; A total of 41 patients (41 eyes) with bullous keratopathy and concomitant II-III stage glaucoma were enrolled. All patients underwent endothelial keratoplasty of different modification--DSAEK, utDSAEK, DMAEK. Two types of glaucoma drainage surgery were applied--intrascleral amniotic drainage and implantation of a domestically manufactured silicone tubular drainage wrapped in amnion. RESULTS: Intraocular pressure (IOP) was compensated in 11 of 12 patients, on whom a glaucoma procedure was performed. In 29 post-keratoplasty patients, whose IOP was compensated both before and after the surgery, the mean IOP at the 2-year follow-up visit was 2 mm Hg higher than the preoperative values. Medication regimen was adjusted in 7 cases in order to enhance the hypotensive effect. No evident correlation between graft thickness and IOP change was found. CONCLUSION: Based on a study of 41 patients (41 eyes) with bullous keratopathy and concomitant glaucoma who underwent endothelial keratoplasty, surgical treatment and therapeutic management policy is developed, which takes into account whether or not the IOP is compensated and whether or not its further decrease is required and implies the use of own original drainage techniques.

[Lamellar minikeratoplasty for recurrent herpes keratitis in the late post-LASIK period].

The article presents a case report of sutureless lamellar minikeratoplasty for progressive corneal ulceration associated with herpes simplex infection in the late period after LASIK.

[Laser discission of a host descemet membrane after endothelial keratoplasty].

A case of YAG-laser discission of a hazy host descemet membrane left in anterior chamber after endothelial keratoplasty is presented.