Patient-reported outcomes of autologous serum tears for the treatment of dry eye disease in a large cohort.

PURPOSE: To assess patient satisfaction with autologous serum tears (AST) for the treatment of dry eye disease (DED). METHODS: A prospective, observational case-series, including 100 participants who were treated with AST for DED. The five-item Dry Eye Questionnaire (DEQ-5), Symptom Assessment in Dry Eye (SANDE) Questionnaire, and the Treatment Satisfaction Questionnaire for Medication (TSQM) were used to assess DED symptoms and patients' treatment satisfaction. RESULTS: The duration of AST treatment was 1-6 months in 25%, 6-12 months in 24%, 1-2 years in 22%, and 2-3 years in 29% of the participants. The mean cumulative DEQ-5 score was 12.7 ±â€¯3.8 and 65% of the participants scored ≥12, which may suggest an underlying diagnosis of Sjögren's syndrome. The use of other treatments was significantly reduced after the use of AST (P < 0.001). The mean total SANDE score improved from 79.5 ±â€¯21.8, 95% CI [75.2, 83.8] before to 42.2 ±â€¯23.2, 95% CI [37.6, 46.8] after using AST (P < 0.001). The mean TSQM treatment efficacy, convenience, and global satisfaction scores were 73.1 ±â€¯17.2, 95% CI [69.6, 76.5], 72.5 ±â€¯17.5, 95% CI [69.0, 76.0], and 74.6 ±â€¯22.7, 95% CI [70.1, 79.0]. No patients reported any side effects. CONCLUSION: Autologous serum tears treatment in severe dry eye disease significantly reduced dry eye symptoms, with high patients' satisfaction scores.

Intravitreal bevacizumab for the treatment of nonarteritic anterior ischemic optic neuropathy: a prospective trial.

PURPOSE: There is currently no accepted treatment for Nonarteritic Anterior Ischemic Optic Neuropathy (NAION). One new therapeutic approach involves decreasing optic nerve edema with intravitreal bevacizumab in order to resolve a proposed compartment syndrome. METHODS: In this non-randomized controlled clinical trial, 1.25 mg intravitreal bevacizumab was compared with natural history. Patients were examined at baseline, 1, 3, and 6 months with a full neuro-ophthalmic exam, automated perimetry, and optic nerve optical coherence tomography (OCT) measurements. The primary outcome measure was change in mean deviation on Humphrey visual field testing. Secondary outcome measures were change in visual acuity and optic nerve OCT thickness. Incidence and type of complications were also recorded. RESULTS: Twenty-five patients were enrolled (17 treatment and 8 control). There was no significant effect of treatment on the primary outcome measure of mean deviation score (P=0.4). There was similarly no effect of group assignment on the secondary outcome measures of change in mean Early Treatment Diabetic Retinopathy Study letters (P=0.33) or nerve fiber layer thickness on OCT (P=0.11). In the bevacizumab group, there was one case of a corneal abrasion and two cases of recurrent NAION. No other complications were noted. CONCLUSIONS: We found no difference between bevacizumab and natural history for change in visual field, visual acuity, or optic nerve OCT thickness. Based on the current evidence we would not recommend the use of intravitreal bevacizumab to treat patients with the new onset of NAION.

Half top hat wound configuration for penetrating keratoplasty: 1-year results.

AIMS: To compare the 1-year outcomes after half-top-hat (HTH) penetrating keratoplasty (PK) versus top-hat (TH) PK and regular PK. METHODS: We reviewed the clinical notes of 87 consecutive patients who had undergone either HTH PK (23 eyes), TH PK (36 eyes) or regular PK (35 eyes) at Toronto Western Hospital between 2002 and 2007. We evaluated best-corrected visual acuity (BCVA), topographic and refractive results, high-order ocular aberrations, endothelial cell counts and complication rates. RESULTS: The three groups of patients did not differ significantly in their demographics (age, gender and laterality), donor endothelial cell counts, preoperative visual acuity or intraocular pressure (IOP). At 12 months postoperatively, BCVA was similar in the three groups, as was the mean spherical equivalent and cylinder. The time to sutures removal was significantly shorter in the HTH PK versus regular PK groups (3.8 (1.2) vs 9.7 (1.1) months, p<0.0001), and the endothelial cell counts were significantly higher (p = 0.003). The IOP was higher in the HTH PK patients than in regular PK patients (p = 0.04). All high-order aberrations tested were significantly higher in the HTH PK than in the regular PK groups (p<0.01). Regular PK had a higher rate of astigmatism treated with relaxing incisions (n = 7 vs n = 2 in HTH PK) and dehiscence of wound incision (n = 2, versus n = 0 in HTH PK). CONCLUSIONS: BCVA and refractive results are similar after half-top-hat, top-hat and regular PK. Half-top-hat PK substantially speeds up visual recovery and contributes to significantly higher endothelial cell counts in the grafts 1 year after surgery.

Fibrin glue versus sutures for attaching the conjunctival autograft in pterygium surgery: a prospective observer masked clinical trial.

AIMS: To compare the degree of conjunctival autograft inflammation, subconjunctival haemorrhage (SCH) and graft stability following the use of sutures or fibrin glue (FG) during pterygium surgery. METHODS: Prospective, observer masked, clinical trial. 40 eyes of 40 patients undergoing primary pterygium surgery with conjunctival autograft were allocated into two groups. Group 1 (n = 20) had FG (Tisseel) for attaching the conjunctival autograft, whereas group 2 (n = 20) had sutures. Standardised digital slit-lamp photographs were taken at 1 week, 1 month and 3 months postoperatively. Sutures were masked using commercially available photo-editing software. Two masked observers objectively graded the digital photographs for degree of inflammation, SCH and graft stability. RESULTS: 34 of the 40 patients completed the study. When using FG, the degree of inflammation was significantly less than with sutures at 1 month (p = 0.019) and 3 months (p = 0.001) postoperatively. No significant difference was found for inflammation at 1 week postoperatively (p = 0.518). Conjunctival grafts secured with FG were as stable as those secured with sutures (p = 0.258, p = 0.076 and p = 0.624, at 1 week, 1 month and 3 months, respectively). No significant difference was found in degree of postoperative SCH between the groups (p = 0.417, p = 1 and p = 1, at 1 week, 1 month and 3 months, respectively). CONCLUSION: This is the first prospective clinical trial confirming that conjunctival grafts secured with FG during pterygium surgery not only are as stable as those secured with sutures, but also produce significantly less inflammation.

Posterior lamellar keratoplasty--comparison of deep lamellar endothelial keratoplasty and Descemet stripping automated endothelial keratoplasty in the same patients: a patient's perspective.

AIM: To evaluate patients' perspectives on endothelial keratoplasty and to compare the outcomes of deep lamellar endothelial keratoplasty (DLEK) and Descemet stripping automated endothelial keratoplasty (DSAEK), performed in the same patients. METHODS: A fellow eye, comparative retrospective case series. The records of 14 patients (28 eyes) who underwent DLEK in one eye and DSAEK surgery in their fellow eye between 2003 and 2007 were reviewed. Two patients were excluded from the study. Both these techniques were compared for intra- and postoperative complications, visual and refractive outcomes including higher-order ocular aberrations (HOA). Patient satisfaction for both procedures was prospectively evaluated using a subjective questionnaire. RESULTS: Nine (75%) of the 12 patients perceived better vision in the DSAEK operated eye. Eight (66.6%) of the patients reported faster recovery following DSAEK. Ten (83%) of them preferred the outcomes of the DSAEK surgery. The intra- and postoperative complications were comparable between both procedures. There was no significant difference in visual outcomes between the procedures. However, the DLEK procedure was associated with a significantly higher degree (p<0.05) of HOA. Endothelial cell loss was similar following DLEK and DSAEK. CONCLUSIONS: We conclude that most patients prefer the DSAEK operation, although there are no differences in visual outcomes between DLEK and DSAEK. Avoidance of surgery-induced hyperopia and HOA is the main benefit of the DSAEK technique.

Femtosecond laser versus manual dissection for top hat penetrating keratoplasty.

AIM: To compare the outcomes of IntraLase-enabled top hat penetrating keratoplasty (IEK) versus retrospective results of manual top hat penetrating keratoplasty (TH-PKP) and conventional PKP. PATIENTS/METHODS: This non-randomised prospective study included 94 eyes: 23 eyes underwent IEK, 36 TH-PKP and 35 conventional PKP. Preoperative and postoperative manifest refraction, uncorrected and best-spectacle corrected visual acuity (BSCVA), high-order ocular aberrations (HOA), endothelial cell counts and complications were analysed. RESULTS: At 12 months of follow-up, the mean log MAR BSCVA was 0.32 (SD 0.31) in the IEK group, 0.53 (0.36) in the TH PKP group (p = 0.03) and 0.39 (0.30) in the conventional PKP group (p = 0.4). The mean spherical equivalent was similar between the groups and was less than -2.2 dioptres. The mean cylinder was similar in the IEK and conventional PKP group (3.6 (1.9) dioptres and 4.1 (1.8) dioptres, respectively), and was significantly lower than the TH-PKP group (5.1 (3.2) dioptres, p = 0.04). The complications rate and high-order ocular aberrations were similar between the three groups studied. The mean endothelial cell loss was significantly lower at 12 months of follow-up in the IEK and the TH-PKP groups versus conventional PKP (32.4% and 22.3% vs 40.8%, respectively) (p = 0.05). The mean time to suture removal was 4.1 (1.2) months in the IEK group and 3.9 (1.5) months in the TH-PKP group versus 9.7 (1.1) months in the conventional PKP group (p<0.0001). CONCLUSIONS: IEK is a safe and stable procedure. It results in higher endothelial counts and faster suture removal in comparison with the conventional PKP, and has less astigmatism and better BSCVA in comparison with the manual TH-PKP.

Corneal wound malapposition after penetrating keratoplasty: an optical coherence tomography study.

AIMS: To examine the wound configuration after penetrating keratoplasty (PKP) using anterior segment optical coherence tomography (OCT). METHODS: All PKP patients who were examined for routine follow-up, between November and December 2006, after having all their sutures removed were included. Patients underwent clinical examination, refraction, corneal topography, aberrometry and Visante anterior segment OCT. RESULTS: 204 graft-host sections from 27 eyes (25 patients, mean age 51.6 (SD 17.7) years) were analysed. Although all the graft-host junctions had continuous smooth epithelial surfaces, 124 of them (60.8%) had internal graft-host malappositions such as gapes (15.7%), steps (30%) or protrusions (15.2%). Keratoconus patients had significantly more graft steps (p<0.05) while those transplanted for endothelial dysfunctions had more protrusions (p<0.01). Graft oversizing significantly increased the size of malappositions. Internal gapes or steps significantly reduced the graft-host touch. Intraocular pressure (IOP), final refraction and final keratometric cylinder were all significantly correlated with the presence and size of the malapposition, while steeper keratometry and tilt aberrations correlated with diminished graft-host touch. CONCLUSIONS: After PKP, internal graft-host malapposition is relatively common and associated with increased ametropia, astigmatism, IOP and optical tilt aberrations.

Half-top-hat--a new wound configuration for penetrating keratoplasty.

AIMS: To describe a new, simpler method of achieving the advantages of a lamellar wound configuration in penetrating keratoplasty (PKP)--the half-top-hat (HTH) configuration. METHODS: The donor corneal button was prepared in a top-hat configuration, as previously described. It consisted of a central, full-thickness part, 7-8 mm in diameter, surrounded by a peripheral lamellar wing of deep stroma and endothelium that was 0.5 mm in width (wing diameter 8-9 mm). The recipient bed was prepared by a straight full thickness trephination with a suction trephine. The donor button was positioned by sliding the peripheral wing under the recipient bed. Sixteen 10-0 interrupted sutures and a single continuous 16-bite 11-0 nylon sutures were placed. The interrupted sutures were passed so as to go through the wing, in order to ensure a good apposition of the wing to the inner corneal surface of the recipient. Anterior segment optical coherence tomography (Visante OCT) was used to image the position and alignment of the corneal graft postoperatively. RESULTS: Ten eyes of 10 patients (mean (SD) age: 73.7 (11.4) years, 7 females) underwent HTH PKP. The donor lenticule diameter was 7.7 (0.3) mm (wing diameter 8.7 (0.3) mm). The mean follow-up time was 2.4 (0.7) months. The last median visual acuity was 20/200 (range 20/80-counting fingers), and the last IOP was 18.2 (8.8) mm Hg. No major intraoperative complications were noted. No postoperative events of graft rejection were documented. No anterior surface misalignment was noted either clinically or by OCT. One patient had a rise in IOP postoperatively. CONCLUSIONS: Half-top-hat wound configuration is a valid alternative in penetrating keratoplasty. Its advantages include better apposition of donor and recipient corneas, improved tectonic strength to prevent graft dehiscence, the possibility of early sutures removal and being a simpler procedure to perform.

Optisol vs Dexsol as storage media for preservation of human corneal epithelium.

PURPOSE: To compare the efficacy of two storage media, Optisol GS and Dexsol, in preservation of donor corneal epithelium. METHODS: A total of 12 pairs of corneas not suitable for transplantation, all with intact epithelium, were used in this study, with one cornea of the pair stored in Optisol GS and its other counterpart in Dexsol. At each of three durations of storage--1, 2, and 4 days--four of these paired corneas were prepared for light microscopy and scanning and transmission electron microscopy. Another four pairs of control cornea were prepared in the same way and placed in universal fixative. MAIN OUTCOME MEASURES: Evaluation of the corneas was made by two observers masked as to the identity of the storage medium and length of storage. Loss of epithelial cells was evaluated by light microscopy. The attachment of the epithelium to the basement membrane,cellular integrity, intercellular junctions, and intracellular organelles were evaluated and compared by electron microscopy. RESULTS: The magnitude of epithelial loss correlated with the length of storage time. Control corneas maintained normal epithelium with preservation of all epithelial cell layers. Corneas stored for 1 day had minimal damage of the epithelium. Corneas stored for 2 days had a slight increase in epithelial damage, and corneas stored for up to 4 days showed a marked increase in epithelial damage. There were no significant differences between the two storage media. The basal cell layer was maintained in both the media at all time points, usually in good condition with mild-to-moderate damage in some cases. CONCLUSIONS: Loss of donor epithelium is related mainly to the length of storage and is similar in both Optisol GS and Dexsol. The storage time should be less than 4 days,especially when performing penetrating keratoplasty on patients with ocular surface disorders.

A molecular perspective on corneal dystrophies.

Corneal dystrophies refer to a group of corneal diseases and that are genetically determined. These have been traditionally classified with respect to the layer of cornea involved. We now know that this does not reflect the underlying pathobiology. Most of the corneal dystrophies are of Mendelian inheritance with some phenotype diversity and a variable degree of penetrance. The dystrophies involving enzymatic processes tend to be of autosomal recessive inheritance. In some cases, such as keratoconus, the inheritance pattern is not always clear and is considered complex. The age of onset of the disease, as in most inherited eye disorders, is variable and does not reflect the underlying pathogenic defect. Few cases are congenital. Our understanding of corneal dystrophies is undergoing somewhat of a revolution as over 12 chromosomes have been associated with corneal dystrophies with mutations identified in at least 14 genes if one includes anterior segment dysgenesis in this group of conditions. Several dystrophies remain without a gene or a genetic location (locus) and more familial studies are required. The new molecular information is challenging the traditional thinking about these conditions that was usually guided by the histopathological findings. As this new knowledge becomes more refined, the classification of this group of disorders will eventually be revisited to have a molecular basis. The elucidation of the underlying biochemical pathways may allow us to envisage the possibility of modulating these phenotypes in the future.

Clinicopathological correlation of congenital corneal opacification using ultrasound biomicroscopy.

AIM: To investigate the correlation between clinical, high frequency ultrasound biomicroscopy (UBM) and, where possible, histological findings in cases of congenital corneal opacification presenting to the departments of ophthalmology, Great Ormond Street Hospital for Children, London, and the Hospital for Sick Children, Toronto, Canada. METHOD: 22 eyes of 13 children (age range 3-225 days) with congenitally opaque corneas were examined. UBM was performed using the ultrasound biomicroscope (Allergan-Humphrey). All eyes underwent penetrating keratoplasties (PKP) except five. The host corneas were all sent for histological examination. RESULTS: The final diagnosis in our series was Peters' anomaly in nine cases (70%), corneal dystrophy in two cases (15%), and sclerocornea in two cases (15%). The UBM findings changed the clinical diagnosis in five cases (38%). In these five cases histology was available in four and confirmed the UBM diagnosis in each case. In no case of the 13 where histology was available did it contradict the UBM findings. In two cases a hypoechoic region in the anterior stroma was seen on UBM which correlated histologically with absent Bowman's layer and oedema. In two cases UBM revealed aniridia and in one, congenital aphakia, which was not apparent clinically. CONCLUSION: UBM examination is not only very useful in evaluating the clinical diagnosis in congenital corneal opacification, it also acts as a preoperative guide in cases undergoing PKP by detecting keratolenticular and iridocorneal adhesions and other ocular abnormalities such as aniridia and congenital aphakia. In all cases where PKP was performed the UBM diagnosis was confirmed histologically. The clinical diagnosis was incorrect in five cases. This has important implications in studies of phenotype/genotype correlation of congenital corneal opacification.

Tyrosinemia type II: nine cases of ocular signs and symptoms.

PURPOSE: To report nine cases of tyrosinemia type II, with ocular signs and symptoms. METHODS: Participants included nine patients (18 eyes) who were followed for a mean follow-up period of 6.5 years (range, 2 to 8 years). Intervention included dietary restriction of tyrosine and phenylalanine, which led to resolution of ocular and cutaneous lesions, improved behavior in one patient, and may have prevented developmental delay in others. The main outcome measures were visual acuity and serum tyrosine levels to determine the response to dietary therapy. Intelligence testing and developmental screening were performed when appropriate. RESULTS: All patients presented with ocular signs and symptoms as the primary manifestation of disease and serve to illustrate the typical ocular findings of this syndrome. Three patients presented with cutaneous manifestations, and one patient had mild mental impairment at the time of diagnosis. CONCLUSIONS: Recalcitrant pseudodendritic keratitis may be the presenting sign in tyrosinemia type II. Awareness of the presenting signs and symptoms may accelerate the diagnosis and dietary intervention. Initiation of a tyrosine-restricted and phenylalanine-restricted diet in infancy is most effective in preventing cognitive impairment.

Corneal temperature reversal after storage in Chen medium compared with Optisol GS.

PURPOSE: To compare corneal endothelial cell function by measuring corneal thickness during temperature reversal between corneas stored in two different storage media, Optisol GS and Chen Medium (CM). METHODS: Twenty paired corneas from 10 human donors were randomly assigned for storage at 4 degrees C in Optisol GS (10 corneas) or CM (10 corneas). The storage media were masked, and measurements were done in a masked fashion. After storage for 48 hours, corneal thickness was measured by ultrasonic pachymetry at 2-hour intervals for 12 hours, during which time the corneas were perfused with BSS (balanced salt solution) Plus at 37 degrees C. Scanning electron microscopy of two pairs of corneas from two donors was performed to assess ultrastructural change after 12 hours of warming. RESULTS: Corneal thickness decreased during the first 4 hours of the warming period and then increased during the 6-to 12-hour warming period. These changes in corneal thickness over time were similar for the two storage media (p = 0.212). Scanning electron microscopy showed greater amounts of endothelial cell disruption in Optisol GS-stored corneas than those stored in CM after 12 hours of warming and perfusion. CONCLUSIONS: The endothelial pump of corneas stored in CM appear to be as well-preserved as those stored in Optisol GS, although greater endothelial disruption may be present with Optisol GS by scanning electron microscopy. Further studies are required to compare the clinical effectiveness of these two media.

Detection of hepatitis C virus in the corneas of seropositive donors.

PURPOSE: There have been no reported cases of hepatitis C virus (HCV) transmission by corneal transplantation. Previous studies have also shown no correlation between HCV seropositivity and the presence of HCV RNA in the corneal tissues. This study aims to investigate such correlation and to provide further evidence to the possible transmissibility of HCV via corneal grafts. METHODS: Of the 1,619 potential corneal donors to the Eye Bank of Canada over a 1-year period, 15 tested HCV-positive by the second-generation Abbott HCV enzyme immunoassay (EIA) 2.0 assay. Their sera were further tested with second-generation radio-immunoblot assay (RIBA-II), and their corneas (29 altogether) were processed for identification of HCV RNA using polymerase chain reaction (PCR). RESULTS: Of the 29 corneas from seropositive donors, HCV RNA was detected in 7 (24.1%). CONCLUSION: This is the first study in the literature that demonstrates a significant correlation between HCV seropositivity and the presence of HCV in the corneas. Routine HCV serologic testing for all potential corneal donors and rejection of corneal tissues based on HCV seropositivity is certainly justifiable.

Dislocation of a plate-haptic silicone intraocular lens into the anterior chamber.

Posterior dislocation is a well-described complication of plate-haptic intraocular lenses (IOLs). It usually occurs after an opening in the posterior capsule, either intraoperatively or after a neodymium: YAG capsulotomy occurs. We report a case of anterior luxation of a plate-haptic silicone IOL occurring 4 months after uneventful cataract surgery. This case emphasizes the need for a small and continuous capsulorhexis as well as in-the-bag implantation of plate-haptic IOLs.

Foldable silicone versus poly(methyl methacrylate) intraocular lenses in combined phacoemulsification and trabeculectomy.

PURPOSE: To compare the outcome of phacotrabeculectomy with implantation of poly(methyl methacrylate) (PMMA) or foldable silicone intraocular lenses (IOLs). METHODS: Thirty patients were randomized to receive a 5.5 mm PMMA IOL through a 5.0 mm incision or a foldable silicone IOL (Allergan SI-30) through a 3.2 mm incision. Visual acuity, intraocular pressure (IOP), bleb survival, inflammation, endothelial cell changes, and complications were examined at intervals up to 6 months. RESULTS: There was no difference between the 2 groups in final visual outcome, final IOP control, bleb survival, and endothelial cell changes. Two months after surgery, there was significantly more inflammation in the silicone IOL group than in the PMMA group (P <. 05). The silicone group had a significantly higher combined complication rate including iris capture, choroidal effusion, and epiretinal membrane formation (P <.05). CONCLUSIONS: Foldable silicone IOLs were comparable to conventional PMMA lenses in visual outcome, IOP control, bleb formation, and endothelial changes. However, some silicone lenses are associated with an increased risk of recurrence of inflammation and a higher final complication rate in combined cataract and filtration surgery.

Long-term results of transscleral Nd:YAG cyclophotocoagulation for refractory glaucoma postpenetrating keratoplasty.

PURPOSE: To determine the effects of noncontact transscleral Nd:YAG cyclophotocoagulation (NCTY) in the treatment of refractory glaucoma postpenetrating keratoplasty (PKP) with respect to intraocular pressure (IOP), corneal graft survival, and reduction of glaucoma medications. METHODS: The records of all patients treated with NCTY for refractory glaucoma after PKP at the authors' institution over an 11-year interval were reviewed. The LASAG noncontact Nd:YAG laser (Lasag AG; Thun, Switzerland) was used. Approximately 40 laser applications were delivered per eye. Visual acuity, IOP, glaucoma medications, and corneal graft clarity were evaluated. RESULTS: Fifty-two eyes met the inclusion criterion. The mean pretreatment IOP was 38.7+/-11.9 mm Hg. The mean posttreatment IOP was 15.8+/-9.7 mm Hg. From life table analysis, the probability of having a posttreatment IOP of 21 mm Hg or less with or without medication was 70% at 1 year and 63% at 5 years. The probability of a graft remaining clear was 79% at 1 year and 56% at 5 years. In 85% of patients the visual acuity remained stable, in 11% the visual acuity improved, and in 4% the visual acuity deteriorated after treatment. One patient developed hypotony. Twenty patients (36.5%) were able to discontinue one or more glaucoma medications posttreatment. CONCLUSION: In this group of patients with PKP glaucoma, NCTY effectively lowered IOP over the long term, with 36.5% of patients discontinuing one or more glaucoma medications. There was, however, a significant incidence of graft failure at 5 years.