Refractive, topographic, and visual outcomes of same-day corneal cross-linking with Ferrara intracorneal ring segments in patients with progressive keratoconus.

PURPOSE: To report refractive, topographic, and visual outcomes 12 months after same-day treatment with corneal cross-linking (CXL) and Ferrara intracorneal ring segments (ICRS) in eyes with progressive keratoconus (KC) and contact lens intolerance. METHODS: This was a case series of 7 eyes (7 patients) with progressive mild to moderate keratoconus and contact lens intolerance undergoing implantation of Ferrara ICRS immediately followed by corneal cross-linking. Uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BSCVA), refractive error, pachymetry, and keratometry were evaluated at 3, 6, and 12 months of follow-up. RESULTS: Mean follow-up was 11.7 ± 3.6 months (range, 5-17 months). Mean preoperative UCVA and BSCVA were 0.10 ± 0.07 (range, 0.05-0.2) and 0.56 ± 0.08 (range, 0.5-0.7), respectively. One year after the treatment, mean UCVA and BSCVA measured 0.60 ± 0.24 (range, 0.32-0.9) and 0.82 ± 0.25 (range, 0.5-1.2), respectively. The mean spherical equivalent decreased significantly (P < 0.05) with 3.5 diopters (D). Mean K values (average keratometry of the cornea) decreased from 46.81 ± 2.13 D (range, 44-51 D) to 43.97 ± 2.22 D (range, 42-47.5 D) 1 year after the treatment. The average preoperative thinnest pachymetry measured 462 ± 46 µm (range, 410 ± 546 µm) and did not change significantly after the treatment. In patient 1, the inferior ICRS was removed 5 months postoperatively because of implant migration. CONCLUSIONS: The combined treatment of corneal cross-linking and Ferrara ICRS is a safe procedure that may be considered in patients with progressive mild to moderate KC and contact lens intolerance.

A posterior khodadoust line in a graft rejection episode after descemet stripping automated endothelial keratoplasty.

PURPOSE: To describe the presence of an endothelial rejection line in immunological graft rejection after Descemet stripping automated endothelial keratoplasty (DSAEK). METHODS: Case report. RESULTS: A 77-year-old woman underwent DSAEK procedure of the left eye because of visual limiting bullous keratopathy. One week postoperatively, the donor lamella was partially detached and an additional air bubble was injected into the anterior chamber. Thereafter, complete adherence of the lamella was seen. Four months after surgery, vision deteriorated, and a transient immunological graft rejection episode with endothelial rejection line was seen. CONCLUSIONS: In contrast to other reports, an endothelial rejection line (Khodadoust line) can be seen during the endothelial rejection episode after DSAEK.

Long-term follow-up of hydrogel intracorneal lenses in 2 aphakic eyes.

We report the outcome of hydrogel intracorneal lens implantation in 2 patients. The lenses were implanted at approximately 50% depth in the cornea to correct high hyperopic refractive errors of 10.5 diopters (D) and 14.0 D, respectively. Both patients were contact lens intolerant and not suitable for intraocular lens implantation. Surgery was performed in 1988, and the patients were followed until early 2010. The patients showed good tolerance for the intracorneal lenses, but both developed opacities around the implant, leading to reduced visual acuity in 1 patient. Long-term patient monitoring is essential since corneal opacities can develop after many years. Removing the implant is not necessary as the lens can easily be rinsed by lifting the corneal cap.

A genome-wide association study identifies a susceptibility locus for refractive errors and myopia at 15q14.

Refractive errors are the most common ocular disorders worldwide and may lead to blindness. Although this trait is highly heritable, identification of susceptibility genes has been challenging. We conducted a genome-wide association study for refractive error in 5,328 individuals from a Dutch population-based study with replication in four independent cohorts (combined 10,280 individuals in the replication stage). We identified a significant association at chromosome 15q14 (rs634990, P = 2.21 × 10⁻¹4). The odds ratio of myopia compared to hyperopia for the minor allele (minor allele frequency = 0.47) was 1.41 (95% CI 1.16-1.70) for individuals heterozygous for the allele and 1.83 (95% CI 1.42-2.36) for individuals homozygous for the allele. The associated locus is near two genes that are expressed in the retina, GJD2 and ACTC1, and appears to harbor regulatory elements which may influence transcription of these genes. Our data suggest that common variants at 15q14 influence susceptibility for refractive errors in the general population.

Preliminary results of femtosecond laser-assisted descemet stripping endothelial keratoplasty.

OBJECTIVE: To evaluate the preliminary visual results of femtosecond laser-assisted Descemet stripping endothelial keratoplasty (FS-DSEK). METHODS: We prospectively analyzed results of 20 consecutive patients with Fuchs endothelial dystrophy or aphakic/pseudophakic bullous keratopathy who underwent FS-DSEK. Best spectacle-corrected visual acuity (BSCVA), refraction, corneal topography, and endothelial cell density were measured preoperatively and 3 and 6 months after FS-DSEK. Corneal thickness was measured using an optical coherence tomography technique. RESULTS: The average BSCVA of 11 eyes with normal visual potential significantly improved from 20/110 +/- 4 lines to 20/57 +/- 1 line at 6 months (P < .007). At 6 months, the mean (SD) hyperopic shift was 2.24 (2.3) diopters (D). Preoperative and 6 months postoperative refractive astigmatism were -0.75 (0.9) D and -1.58 (1.1) D (P = .01), but the topographic astigmatism did not change postoperatively (P = .95). Mean (SD) endothelial cell density at 6 months was 1368 (425) cells/mm(2). There was a persistent deswelling of the graft up to 3 months postoperatively. Complications included graft dislocations requiring repositioning (20%), pupillary block glaucoma (5%), epithelial ingrowth (5%), and primary graft failure (5%). CONCLUSIONS: Femtosecond laser-assisted Descemet stripping endothelial keratoplasty was effective in treating endothelial failure with minimal induced refractive astigmatism, limited improvement of BSCVA, and induction of a hyperopic shift. Endothelial cell count and dislocation rate were significant, which may be related to the surgical technique.

Prospective clinical evaluation of McCarey-Kaufman and organ culture cornea preservation media: 14-year follow-up.

PURPOSE: To compare the outcome of corneal grafts preserved in McCarey-Kaufman (MK) medium versus organ culture after penetrating keratoplasties. METHODS: Paired corneas were stored in McCarey medium for 2-44 hours (mean 21 hours) and in organ culture (OC) for 144 -240 hours (mean 192 hours). Penetrating keratoplasties were performed by 2 surgeons in 2 groups of patients with keratoconus, matched for age. Each pair was transplanted by the same surgeon using the same technique. Visual acuity, central corneal thickness, and central endothelial cell density were assessed at 166 +/- 7.8 months postoperatively. RESULTS: Nine pairs of patients were recovered for a long-term follow-up. The mean endothelial cell densities for the MK and OC groups were 611 +/- 155 and 683 +/- 168 cells/mm, respectively, which were not significantly different. A first rapid cell loss rate of 2.07% and 2.52% per month and a second slow of 0.78% and 0.69% per month were observed in the respective groups. Individual values of best corrected visual acuity were all the same (value 1.00) for both groups. Corneal thicknesses were, respectively, 571 +/- 52 and 540 +/- 35 microm and were significantly different (P = 0.013). CONCLUSIONS: After 14 years of penetrating keratoplasties performed with corneas stored in MK versus OC, no significant differences were observed in visual acuity, endothelial cell density, and cell loss. The observed thinner grafts after OC compared with MK could not be explained.

Manual trephination of mushroom keratoplasty in advanced keratoconus.

PURPOSE: To evaluate the technique of mushroom keratoplasty for patients with advanced keratoconus, with respect to postoperative astigmatism, visual improvement and stability, and endothelial cell count. METHODS: Sixteen eyes of 15 patients with advanced keratoconus received a mushroom keratoplasty at the Erasmus Medical Centre at Rotterdam between April 2003 and May 2006. The donor cornea had a larger anterior stromal lamella (9.0 mm) and a smaller posterior part (7.0 mm). Visual acuity and keratometry were measured at 6, 12, 24, and 36 months. Specular microscopy was performed annually. RESULTS: Best-corrected visual acuity improved significantly (P = 0.003) from 0.25 +/- 0.20 preoperatively to 0.62 +/- 0.22 at 6 months postoperatively. Visual acuity remained stable with a best-corrected visual acuity of 0.70 +/- 0.22 from 1 year onward. At all follow-up periods, mean postoperative astigmatism remained <3.5 D. Mean postoperative astigmatism at 1, 2, and 3 years measured 2.67 +/- 1.95 (n = 15), 2.54 +/- 1.86 (n = 6), and 3.30 +/- 2.12 D (n = 5). The average endothelial cell count at 1 and 2 years was 1755 +/- 678 (n = 12) and 1573 +/- 546 cells/mm2 (n = 5), respectively. At the end of follow-up, all transplants remained functional and clear. CONCLUSIONS: The mushroom-shaped graft can combine the benefits of a good visual acuity, a low astigmatism, and rapid postoperative healing. The short-term results of our limited series of patients are encouraging. Further research is necessary to draw stronger conclusions regarding the long-term effects.

Posterior mushroom keratoplasty in patients with Fuchs endothelial dystrophy and pseudophakic bullous keratopathy: transplant outcome.

PURPOSE: To report the outcome of posterior mushroom or top-hat-shaped keratoplasty for patients with Fuchs endothelial dystrophy (FED) or pseudophakic bullous keratopathy (PBK), concerning postoperative astigmatism, visual improvement, and endothelial cell density. METHODS: Twenty-two eyes of 21 patients who received a posterior mushroom keratoplasty for FED (n = 19) or PBK (n = 3) between March 2003 and January 2006 at the Erasmus MC, Rotterdam, The Netherlands, were included. Visual acuity, refraction, and keratometry were measured at 6, 12, 24, and 36 months. Specular microscopy was performed annually. RESULTS: Best-corrected visual acuity (BCVA) significantly (P < 0.05) improved from 0.25 preoperatively to 0.47 at 6 months and 0.64 at 1 year postoperatively. Visual acuity remained stable with a BCVA of 0.62 2 years and 0.69 3 years after keratoplasty. At the last follow-up, the BCVA measured 0.5 or more in all but 2 (91%) eyes. Mean postoperative astigmatism at 1, 2, and 3 years measured 2.72 +/- 1.48, 2.69 +/- 1.85, and 1.75 +/- 1.76 D. Endothelial cell density averaged 2143 +/- 428 cells/mm2 at 1 year, 1539 +/- 573 cells/mm2 at 2 years, and 1920 +/- 474 cells/mm2 at 3 years. All studied transplants remained functional and clear throughout the follow-up period. CONCLUSIONS: The posterior mushroom keratoplasty in FED and PBK results in a relatively good visual acuity, low astigmatism, and good endothelial cell density. The short-term results of our limited series of patients are encouraging.

Femtosecond laser-assisted inverted mushroom keratoplasty.

PURPOSE: To evaluate best-corrected visual acuity (BCVA), refractive outcome, corneal topography, optical coherence tomography, and endothelial cell density 12 months after femtosecond laser-assisted inverted mushroom keratoplasty. METHODS: We performed a prospective study of a surgical case series of 5 patients undergoing femtosecond laser-assisted inverted mushroom keratoplasty for pseudophakic bullous keratopathy or pre-Descemet X-linked ichthyosis. The femtosecond laser was used to create a top-hat configuration in the donor cornea and recipient cornea. Laser parameters were as follows: energy, 4.0 (anterior inner vertical side cut and horizontal lamellar cut) and 7.0 microJ (posterior outer vertical side cut); spiral pattern with a firing rate of 15 kHz. The size of the anterior inner diameter was 7.4 mm in the donor cornea and 7.0 mm in the recipient cornea. The posterior outer diameter was 9.0 mm in all eyes. RESULTS: At 6 and 12 months after surgery, all corneal grafts were clear and showed an excellent adaptation of the lamellar donor and recipient wound surfaces. At 12 months postoperatively, BCVA averaged 20/32 (range, 20/60-20/20), refractive cylinder averaged -3.20 +/- 2.0 D, topographical cylinder averaged 3.26 +/- 2.1 D, and the mean endothelial cell density was 1793 +/- 491 cells/mm2 (range, 954-2237 cells/mm2). The mean central corneal thickness and thickness of the posterior shelf was 517 +/- 3 and 175 +/- 8 microm, respectively. CONCLUSIONS: The femtosecond laser-assisted inverted mushroom keratoplasty shows good promise in surgical treatment of corneal diseases. The multiplanar fit between the donor and recipient cornea allows early suture removal and visual rehabilitation.

Long-term follow-up of endothelial cell change after Artisan phakic intraocular lens implantation.

OBJECTIVE: To report endothelial cell densities (ECDs) and their correlation to anterior chamber depth (ACD) after implantation of the Artisan intraocular phakic lens. DESIGN: Prospective observational case series. PARTICIPANTS: Three hundred eighteen eyes of 173 myopic patients treated with the Artisan iris-fixated phakic intraocular lens (IOL). METHODS: Eyes with an ACD ranging between 2.89 and 4.5 mm were implanted with the Artisan phakic IOL. Endothelial cell density measurements were performed preoperatively and at each follow-up examination using a noncontact specular microscope. MAIN OUTCOME MEASURES: Endothelial cell density (cells per square millimeter). RESULTS: Follow-up ranged between 1 (82 eyes) and 7 years (13 eyes) (mean, 35.3+/-20.7 [standard deviation] months per eye). After 3 years, there was a significant loss in ECD (P< or =0.03). At 5 years, mean observed endothelial cell loss was 8.3% (5.3% corrected for a natural endothelial cell loss of 0.6% a year). Endothelial cell density loss remained progressive throughout our follow-up period. After 3 years, a significant negative correlation between ACD and endothelial cell loss was revealed (P< or =0.03). Patient age, gender, refractive error, incision size, and side of the eye were not correlated to ECD loss. All corneas remained clear throughout the study. CONCLUSION: After 3 years, a significant ECD loss was revealed. This ECD loss was significantly negatively correlated to the ACD. We therefore suggest that eyes just meeting the minimum ECD requirement have greater ACDs to compensate for possible greater endothelial cell loss and that patients with shallow anterior chambers have higher ECDs. Artisan phakic lens implantation in young eyes narrowly meeting the minimum criteria of endothelial cell density (2,000 cells/mm(2)) and ACD (2.6 mm) should perhaps be reevaluated, due to longer exposure to higher rates of endothelial cell loss.

The IC3D classification of the corneal dystrophies.

BACKGROUND: The recent availability of genetic analyses has demonstrated the shortcomings of the current phenotypic method of corneal dystrophy classification. Abnormalities in different genes can cause a single phenotype, whereas different defects in a single gene can cause different phenotypes. Some disorders termed corneal dystrophies do not appear to have a genetic basis. PURPOSE: The purpose of this study was to develop a new classification system for corneal dystrophies, integrating up-to-date information on phenotypic description, pathologic examination, and genetic analysis. METHODS: The International Committee for Classification of Corneal Dystrophies (IC3D) was created to devise a current and accurate nomenclature. RESULTS: This anatomic classification continues to organize dystrophies according to the level chiefly affected. Each dystrophy has a template summarizing genetic, clinical, and pathologic information. A category number from 1 through 4 is assigned, reflecting the level of evidence supporting the existence of a given dystrophy. The most defined dystrophies belong to category 1 (a well-defined corneal dystrophy in which a gene has been mapped and identified and specific mutations are known) and the least defined belong to category 4 (a suspected dystrophy where the clinical and genetic evidence is not yet convincing). The nomenclature may be updated over time as new information regarding the dystrophies becomes available. CONCLUSIONS: The IC3D Classification of Corneal Dystrophies is a new classification system that incorporates many aspects of the traditional definitions of corneal dystrophies with new genetic, clinical, and pathologic information. Standardized templates provide key information that includes a level of evidence for there being a corneal dystrophy. The system is user-friendly and upgradeable and can be retrieved on the website www.corneasociety.org/ic3d.

The influence of incision-induced astigmatism and axial lens position on the correction of myopic astigmatism with the Artisan toric phakic intraocular lens.

PURPOSE: To evaluate postoperative astigmatism with regard to incision-induced astigmatism and deviation in axial alignment with the use of preoperative limbal marking with the Javal keratometer (Haag Streit, Bern, Switzerland) in eyes implanted with the Artisan toric phakic intraocular lens (IOL) (Ophtec, Groningen, The Netherlands). DESIGN: Prospective nonrandomized trial. PARTICIPANTS: Fifty-four eyes of 33 patients with myopia (mean, -9.67 diopters [D]) and astigmatism (mean, -3.44 D). INTERVENTION: The enclavation site was marked on the limbus using the Javal keratometer. The Artisan toric phakic IOL was implanted according to the axis marked on the limbus. Follow-up was a minimum of 6 months. MAIN OUTCOME MEASURES: Safety index, efficacy index, predictability, safety, and vector analysis of total refractive correction were determined. The effects of axis misalignment and incision-induced astigmatism on the final refractive error were evaluated. RESULTS: At 6 months after surgery, the safety index was 1.29+/-0.29 and the efficacy index was 1.04+/-0.35. Mean spherical equivalent subjective refraction reduced from -11.39+/-4.86 D before surgery to -0.38+/-0.57 D at 6 months. Sixty-seven percent of eyes were within 0.50 D of attempted refraction and 89% were within 1.00 D. Mean preoperative cylinder was 2.92+/-1.60 D at 91.4 degrees . At 6 months, the mean cylinder was 0.28+/-0.54 D at 174.3 degrees . No eyes lost 2 or more lines of best-corrected visual acuity at 6 months. Eighty-three percent of eyes achieved uncorrected visual acuity of 20/40 and 28% achieved 20/20. Vector analysis of total surgically induced astigmatism revealed a mean cylindrical change of 3.21+/-1.71 D. Average axis misalignment was 0.37+/-5.34 degrees . The mean incision-induced astigmatism was 0.74+/-0.61 D at 0.2 degrees . CONCLUSIONS: Implantation of the myopic toric IOL leads to safe, efficacious, and predictable results. The level of unpredictability caused by minor axis IOL misalignment has minimal effects on the residual refractive error. The procedure of axis alignment with the Javal keratometer seems to be an accurate method of marking the eye for toric IOL implantation. Incision-induced astigmatism can result in an overcorrection of the cylinder. A systematic undercorrection of -0.50 D for attempted cylindrical outcome could result in an achieved correction closer to emmetropia.

Toric phakic intraocular lens for the correction of hyperopia and astigmatism.

PURPOSE: To evaluate the Artisan toric phakic intraocular lens (pIOL) for the correction of hyperopia and astigmatism. SETTING: Department of Ophthalmology, Erasmus MC, Rotterdam, The Netherlands, and Department of Ophthalmology, Sint Truiden, Belgium. METHODS: In this prospective study of 47 eyes of 28 patients with hyperopia and astigmatism, Artisan toric pIOLs were implanted between April 1999 and June 2004. Uncorrected visual acuity (UCVA), best corrected visual acuity, refraction, astigmatism, safety, and predictability were analyzed. Change in astigmatism was analyzed with vector analysis. Refractive cylinders are expressed in minus form. RESULTS: Mean preoperative spherical equivalent was +4.33 diopters (D) +/- 2.26 (SD). Mean follow-up was 11.1 months (range 6 to 36 months). A gain of 1 or more lines in best spectacle-corrected visual acuity (BSCVA) was seen in 36.2%. Safety index and efficacy index after 6 months were 1.06 and 0.87, respectively. The mean postoperative astigmatism at 6 months was 0.19 D at an axis of 144 degrees. At 6 months, about three quarters (76.6%) of the eyes had a UCVA of 20/40 or better. One eye lost 2 lines of BSCVA. In 1 eye, the lens position had to be changed because of a large axis misalignment. No serious complications developed in any of the treated eyes during follow-up. CONCLUSIONS: Artisan toric pIOLs can correct moderate to high hyperopia combined with astigmatism with good refractive results. In this study, there were no serious complications. However, the predictability of the refractive results appeared to be lower than those in the correction of myopia and astigmatism with toric Artisan lenses.

Implantation of Artisan toric phakic intraocular lenses for the correction of astigmatism and spherical errors in patients with keratoconus.

PURPOSE: To evaluate the correction of astigmatism and spherical ametropia in patients with keratoconus through implantation of an Artisan toric phakic intraocular lens (PIOL) (Ophtec, Groningen, The Netherlands). METHODS: Artisan toric PIOLs were implanted uneventfully in both eyes of three patients with keratoconus with clear central corneas and contact lens intolerance. RESULTS: Best spectacle-corrected subjective visual acuity after lens implantation was unchanged in one eye and improved in five eyes. Spherical equivalent refraction was significantly reduced in all eyes (P=.03). The safety index was 1.49. CONCLUSIONS: The implantation of an Artisan toric PIOL may be an alternative for treating astigmatism and myopia in contact lens intolerant patients with keratoconus with clear central corneas. Especially in patients with associated myopia, this procedure is worth considering before planning a penetrating keratoplasty.

Macrophages play a role in the early phase of corneal allograft rejection in rats.

BACKGROUND: Rat corneal allograft rejection is delayed by repeated local injection of liposomes filled with clodronate (dichloromethylene diphosphonate), which selectively deplete macrophages. Various administration schedules of liposomes were tested to determine the optimum schedule for prevention of graft rejection. Cell subpopulations in the anterior segment of the eye were studied at different time points after transplantation to assess the kinetics of the immune response. METHODS: AO rats were grafted orthotopically with corneal buttons from PVG rats. Postoperatively, rats remained untreated or received clodronate liposomes subconjunctivally. Clodronate liposomes were injected five times on postoperative days (PODs) 0, 2, 4, 6, and 8; or once, on POD 0 or 6; or twice on PODs 0 and 2 or PODs 0 and 6. Grafts were examined for signs of rejection clinically and immunohistologically. RESULTS: All untreated rats rejected their grafts as did all five rats that received clodronate liposomes once on POD 6. In all the other administration schedules tested, graft survival was prolonged compared with the untreated control group (P <0.01). Injections of clodronate liposomes on PODs 0 and 2 proved to be the most effective treatment. Histologically reduced influx of virtually all cell types tested was found in this group. CONCLUSIONS: To prevent or delay graft rejection, it is necessary to administer clodronate liposomes in the early phase after corneal transplantation. These results suggest a role for macrophages in the afferent phase of corneal graft rejection.