Case series of staged lamellar corneal grafting with thin manual Descemet's stripping endothelial keratoplasty, followed by manual deep anterior lamellar keratoplasty, as an alternative to penetrating keratoplasty.

The purpose of this report is to present the outcomes of Descemet's stripping endothelial keratoplasty (DSEK), followed by deep anterior lamellar keratoplasty (DALK), as an alternative to penetrating keratoplasty (PKP) for different indications. Patients in this retrospective case series underwent manual DSEK, followed by manual DALK, for tectonic and/or visual reasons. It includes three cases that underwent DSEK followed by DALK as an alternative to PKP for the following conditions: failed PKP and stromal scarring, aphakic bullous keratopathy and herpetic stromal scarring, and herpetic corneal perforation. All cases had successful anatomical repair with visual improvement. Many corneal conditions involving endothelium and stroma have been traditionally managed with PKP. However, in certain settings with high risk of complications, this might not be an appropriate option. Therefore, for these cases, we propose management with DSEK followed by DALK as an alternative approach in a 'closed anterior chamber' fashion, which can reduce the risk of significant, sometimes irreversible, complications.

One-Year Front Versus Central and Paracentral Corneal Changes After Bowman Layer Transplantation for Keratoconus.

PURPOSE: To report the front corneal versus central and paracentral corneal changes after Bowman layer transplantation for keratoconus in a tertiary hospital in the United Kingdom. METHODS: Five eyes of 5 patients receiving Bowman layer transplant for advanced keratoconus in Royal Gwent Hospital (Newport, United Kingdom) were included. Preoperative and postoperative visual acuity; Kmax; Kmean, and corneal cylinder in the front cornea, 4.5 mm central, and 6 mm central; and corneal thickness were analyzed. RESULTS: Corneal flattening and reduction in corneal astigmatism was observed, more marked in the central and paracentral zone, allowing for improvement in best-corrected visual acuity with the aid of visual correction in 4 eyes. CONCLUSIONS: These results support previous data reporting Bowman layer transplantation as a useful strategy in the treatment of advanced keratoconus and suggest greater attention may be focused on central or paracentral corneal changes.

Caspase-2 Mediates Site-Specific Retinal Ganglion Cell Death After Blunt Ocular Injury.

Purpose: Ocular trauma is common in civilian and military populations. Among other injuries, closed globe blunt ocular trauma causes acute disruption of photoreceptor outer segments (commotio retinae) and retinal ganglion cell (RGC) death (traumatic optic neuropathy [TON]), both of which permanently impair vision. Caspase-2-dependent cell death is important and evidenced in models of RGC degeneration. We assessed the role of caspase-2 as a mediator of RGC and photoreceptor death in a rat blunt ocular trauma model. Methods: Bilateral ballistic closed globe blunt ocular trauma was induced in female Lister-hooded rats and caspase-2 cleavage and localization assessed by Western blotting and immunohistochemistry. Retinal caspase-2 was knocked down by intravitreal injection of caspase-2 small interfering RNA (siCASP2). In retinal sections, RGC survival was assessed by BRN3A-positive cell counts and photoreceptor survival by outer nuclear layer (ONL) thickness, respectively. Retinal function was assessed by electroretinography (ERG). Results: Raised levels of cleaved caspase-2 were detected in the retina at 5, 24, and 48 hours after injury and localized to RGC but not photoreceptors. Small interfering RNA-mediated caspase-2 knockdown neuroprotected RGC around but not in the center of the injury site. In addition, caspase-2 knockdown increased the amplitude of the ERG photopic negative response (PhNR) at 2 weeks after injury. However, siCASP2 was not protective for photoreceptors, suggesting that photoreceptor degeneration in this model is not mediated by caspase-2. Conclusions: Caspase-2 mediates death in a proportion of RGC but not photoreceptors at the site of blunt ocular trauma. Thus, intravitreally delivered siCASP2 is a possible therapeutic for the effective treatment of RGC death to prevent TON.

Oxygen prescription: improving compliance using methods from BMJ Open Quality journal.

Oxygen is an important drug frequently used in the management of acutely unwell hospital patients. However, oxygen overuse can have fatal side effects particularly for those patients at risk of iatrogenic hypercapnia. British Thoracic Society Guidelines state that oxygen must be prescribed for all patients, with target saturations stipulated on the prescription for patient safety. A quality improvement project was undertaken with the aim to improve the oxygen prescription rate across the respiratory ward at a district general hospital, over a period of 3 months. Quality improvement methods were implemented based on data analysis at each stage, following discussion with senior doctors and specialist nurses, and after reviewing previous quality improvement projects published on BMJ Open Quality. The initial interventions of poster reminders and multidisciplinary team education failed to significantly improve the rates of oxygen prescription. Use of a targeted intervention where stickers were placed above oxygen taps significantly improved prescription rate from 20% in the non-targeted group to 60% in the targeted group. This was based on a BMJ Open Quality published improvement method. The current guidelines from the British Thoracic Society, and hospital's own guidelines, advise good oxygen prescribing. However, these recommendations alone are ineffective at achieving compliance among prescribers. Further targeted interventions have shown improvements in oxygen prescriptions and could lead to better clinical practice, patient care and safety.