Real-Time Imaging of Incision-Related Descemet Membrane Detachment During Cataract Surgery.

Importance: Incision-related Descemet membrane detachment (DMD) is a common complication of cataract surgery. Most postoperative severe DMD that leads to corneal decompensation originates from intraoperative incision-related DMD. It is important to determine the incidence, extent, and associated risk factors of intraoperative DMD at each step of surgery to help in formulating precise and effective prevention strategies. Objectives: To investigate the intraoperative development of incision-site DMD associated with a 2.2-mm clear corneal incision during cataract surgery and to analyze its associated factors. Design, Setting, and Participants: In this case series, consecutive, prospectively enrolled 133 patients with cataract 50 to 90 years of age (133 eyes) undergoing coaxial 2.2-mm clear corneal microincision phacoemulsification with intraocular lens (IOL) implantation between January 1 and March 31, 2019, at Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China, were studied. Exposures: Coaxial 2.2-mm clear corneal microincision phacoemulsification with IOL implantation. Main Outcomes and Measures: Real-time incidence and extent of intraoperative incision-related DMD at each step of surgery. Results: Among 133 patients with cataracts (mean [SD] age, 72.3 [8.1] years; 77 [57.9%] female), DMD was encountered in 125 eyes (94.0%), occurring at the following steps: capsulorrhexis (2 [1.6%]), hydrodissection (7 [5.6%]), phacoemulsification (69 [55.2%]), irrigation-aspiration (44 [35.2%]), and IOL implantation (3 [2.4%]). The extent of DMD increased during the operation (mean [SD] difference between final and initial relative DMD length, 22.8% [1.4%]; 95% CI, 20.0-25.6; P < .001). Associations for the extent of DMD found in multivariate stepwise analyses included time of ultrasonography (ß = 0.34; 95% CI, 0.17-0.50; P < .001), equivalent mean ultrasonic power (ß = 87.8; 95% CI, 19.1-156.4; P = .01), and the presence of DMD at the anterior and posterior wound margins (coefficient = 16.7; 95% CI, 6.4-26.9; P = .002). Conclusions and Relevance: The results of this case series suggest that friction of surgical instruments has the greatest association with incisional DMD. Decreasing ultrasonic energy and phacoemulsification time may reduce the severity of incisional DMD.

Combined Penetrating Keratoplasty Followed by Pars Plana Vitrectomy for Firecracker Induced Bilateral Corneal and Intraocular Foreign Body: A Case Report.

Firecracker induced open globe injury is a big challenge for ophthalmic surgeons. Its association with the intraocular foreign body makes the diagnosis and treatment even more difficult resulting in poor anatomical and visual outcomes. We report a case of a 35-year-old male who presented with bilateral, multiple corneal and intraocular foreign body due to firecracker explosion. His vision was limited to hand movement in both eyes. Combined penetrating keratoplasty and cataract surgery were done in both eyes followed by pars plana vitrectomy for intraocular foreign body removal. The final best-corrected visual acuity of the patient stood to be 6/6 and 6/9 in the right and left eye respectively. The encouraging result in our case prompts ophthalmologists for a timely stepwise multidisciplinary approach in all open globe injuries with intraocular foreign body cases having poor initial acuity.

Corneal confocal microscopy identifies greater corneal nerve damage in patients with a recurrent compared to first ischemic stroke.

OBJECTIVES: Corneal nerve damage may be a surrogate marker for the risk of ischemic stroke. This study was undertaken to determine if there is greater corneal nerve damage in patients with recurrent ischemic stroke. METHODS: Corneal confocal microscopy (CCM) was used to quantify corneal nerve fiber density (CNFD), corneal nerve branch density (CNBD), corneal nerve fiber length (CNFL) and corneal nerve fiber tortuosity (CNFT) in 31 patients with recurrent ischemic stroke, 165 patients with a first acute ischemic stroke and 23 healthy control subjects. RESULTS: Triglycerides (P = 0.004, P = 0.017), systolic BP (P = 0.000, P = 0.000), diastolic BP (P = 0.000, P = 0.000) and HbA1c (P = 0.000, P = 0.000) were significantly higher in patients with first and recurrent stroke compared to controls. There was no difference in age, BMI, HbA1c, total cholesterol, triglycerides, LDL, HDL, systolic and diastolic BP between patients with a first and recurrent ischemic stroke. However, CNFD was significantly lower (24.98±7.31 vs 29.07±7.58 vs 37.91±7.13, P<0.05) and CNFT was significantly higher (0.085±0.042 vs 0.064±0.037 vs 0.039±0.022, P<0.05) in patients with recurrent stroke compared to first stroke and healthy controls. CNBD (42.21±24.65 vs 50.46±27.68 vs 87.24±45.85, P<0.001) and CNFL (15.66±5.70, P<0.001 vs 17.38±5.06, P = 0.003) were equally reduced in patients with first and recurrent stroke compared to controls (22.72±5.14). CONCLUSIONS: Corneal confocal microscopy identified greater corneal nerve fibre loss in patients with recurrent stroke compared to patients with first stroke, despite comparable risk factors. Longitudinal studies are required to determine the prognostic utility of corneal nerve fiber loss in identifying patients at risk of recurrent ischemic stroke.

Corneal Damage Effects Induced by a 770-2,500 nm Supercontinuum Light Source.

BACKGROUND AND OBJECTIVES: Widespread applications of supercontinuum (SC) source lead to the possibility of ocular damages. However, the corneal damage effects induced by SC have not been explored before. The objectives of this study are to determine the rabbit corneal injury threshold for SC radiation and to examine whether the existing safety guidelines and standards are suitable for the hazard evaluation of this new kind of light source. STUDY DESIGN/MATERIALS AND METHODS: A series of experiments was conducted in the New Zealand white rabbit model to determine the corneal damage thresholds induced by a 770-2,500 nm SC source, with a corneal 1/e beam diameter of 0.37 mm. Through slit-lamp biomicroscope, optical coherence tomography (OCT), and histopathology the corneal damage characteristics at the threshold level were revealed. By employing the action spectra determined through the analysis of safety guidelines and standards, the damage thresholds for SC source could be compared with the corresponding exposure limits. RESULTS: The determined damage thresholds given in terms of the peak radiant exposure for exposure durations of 2.0 and 10.0 seconds were 2.1 × 103 and 7.4 × 103 J/cm2 , respectively. At threshold level, corneal damages involved the epithelium and the shallower stroma, and no obvious changes could be found in the deep stroma, Descemet's membrane, and endothelium. CONCLUSIONS: The exposure limits for the anterior parts of the eye in the wavelength range of 700-1,200 nm are overly conservative. The obtained results contribute to the knowledge base for the hazard evaluation of SC source. Lasers Surg. Med. © 2019 Wiley Periodicals, Inc.

Fire Ant Punctate Keratopathy: A Novel Diagnosis Based on Clinical and Anterior Segment Optical Coherence Tomography Findings.

PURPOSE: To describe the ocular findings and the long-term outcomes of patients diagnosed with corneal injury due to little fire ants (LFAs). METHODS: This is a retrospective case series of patients evaluated with corneal injury due to LFAs from October 2015 to January 2018 at the Cornea Clinic in Meir Medical Center. Patients underwent anterior segment optical coherence tomography (AS-OCT) imaging during the follow-up. RESULTS: Four patients reported ocular contact with LFAs and presented to our department with unilateral, scattered, small, dense, round, bright white opacities in the anterior corneal stroma, which remained unchanged in appearance over time, despite topical antibiotic and steroid treatment. No inflammatory signs were noted in the anterior chamber. Follow-up was performed clinically using AS-OCT for periods of 9 to 26 months after the incidents. AS-OCT findings demonstrated small, subepithelial, hyperreflective foci at the level of the anterior stroma to a depth of 145 to 250 µm, with posterior shadowing that remained unchanged over time. These findings were well-correlated with biomicroscopy findings. CONCLUSIONS: LFA bites can cause long-lasting corneal injury in humans with characteristic clinical biomicroscopic findings. The corneal lesions do not respond to conventional topical treatment. AS-OCT imaging can be a useful modality for diagnosis and follow-up. Awareness by both patients and ophthalmologists of this clinical entity may be helpful in diagnosis and management.

Comparison of intensity, phase retardation, and local birefringence images for filtering blebs using polarization-sensitive optical coherence tomography.

Polarization-sensitive optical coherence tomography (PS-OCT) allows the recording of depth-resolved polarimetric measurements. It has been reported that phase retardation and local birefringence images can noninvasively detect fibrotic area in blebs after glaucoma surgery. Evaluation of scar fibrosis in blebs is important not only for predicting bleb function, but also for planning revision trabeculectomy. Herein, we characterize the intensity, phase retardation, and local birefringence images of blebs using PS-OCT. A total of 85 blebs from 85 patients who had undergone trabeculectomy were examined. Both phase retardation and local birefringence images detected fibrotic changes in blebs after glaucoma surgery. Phase retardation images detected slight fibrotic change during the early stage after surgery, whereas local birefringence images showed localized fibrotic tissue. There are two main patterns of local birefringence image changes in blebs: plate-like birefringence changes and diffuse changes. The area of plate-like birefringence change was significantly larger in poorly functioning blebs and is thus correlated with bleb function. These data suggest that the plate-like fibrotic change evaluation by PS-OCT may be useful not only for noninvasive evaluation of fibrotic scar tissue in blebs, but also for developing strategies for revision trabeculectomy.

Greater corneal nerve loss at the inferior whorl is related to the presence of diabetic neuropathy and painful diabetic neuropathy.

We assessed whether a measure of more distal corneal nerve fibre loss at the inferior whorl(IW) region is better than proximal measures of central corneal nerve damage in relation to the diagnosis of diabetic peripheral neuropathy(DPN), painful DPN and quality of life(QoL). Participants underwent detailed assessment of neuropathy, QoL using the SF36 questionnaire, pain visual analogue score(VAS), and corneal confocal microscopy(CCM). Corneal nerve fibre density (CNFD), branch density (CNBD) and length (CNFL) at the central cornea and inferior whorl length (IWL) and average(ANFL) and total(TNFL) nerve fibre length were compared in patients with and without DPN and between patients with and without painful DPN and in relation to QoL. All CCM parameters were significantly reduced, but IWL was reduced ~three-fold greater than CNFL in patients with and without DPN compared to controls. IWL(p = 0.001), ANFL(p = 0.01) and TNFL(p = 0.02) were significantly lower in patients with painful compared to painless DPN. The VAS score correlated with IWL(r = -0.36, P = 0.004), ANFL(r = -0.32, P = 0.01) and TNFL(r = -0.32, P = 0.01) and QoL correlated with CNFL(r = 0.35, P = 0.01) and IWL(r = 0.4, P = 0.004). Corneal nerve fibre damage is more prominent at the IW, lower in patients with painful compared to painless neuropathy and relates to their QoL. IWL may provide additional clinical utility for CCM in patients with DPN.

Sclerocorneal graft and sequential removal of melted cornea after severe corneal burn with perforation.

Corneal burn grade IV usually leads to blindness. Several different surgical techniques remain challenging owing to the extensive tissue damage. Here, we introduce a novel technique with a 15 mm corneoscleral and limbal homologous graft combined with sequential autologous corneal removal ab interno, with a vitrectomy probe to save the anterior chamber angle. In vivo anatomy with optical coherence tomography is the surgical key. A large 15 mm sclerocorneal graft is sutured on top of the remainder of the destroyed cornea and sclera after removal of the epithelium and conjunctiva, with anterior synechiolysis if necessary, peripheral iridectomy and conjunctivoplasty. The recipient central corneal stroma is not removed, primarily to protect the anterior chamber angle. After three weeks, the collagenolytic central recipient corneal stroma can be removed with a small 23 g vitrectomy probe, respecting the lens and scleral spur. The corneoscleral graft remains clear under systemic and local immunosuppression. Intraocular pressure is well controlled because the anterior chamber angle is respected. Recurrent corneal erosions need close follow-up. Therapeutic soft contact lenses can support topical therapy. In cases of sclercorneal graft decompensation or rejection after 3-5 years, a new sclerocorneal graft (with limbal donation) seems to be superior to perforating keratoplasty without limbal stem cell transplantation. Repeated sclerocorneal grafts after severe corneal burn with limbal transplantation and maintenance of the complete anterior angle structure are a successful option for preventing blindness and achieving good visual acuity. Clin. Anat. 31:39-42, 2018. © 2017 Wiley Periodicals, Inc.

The optical imaging of tarantula hair corneal injury: One case report and review of the literature.

INTRODUCTION: Tarantulas belonging to the Theraphosidae family are more and more popular as family pets. Ocular injuries caused by tarantulas are reported in several articles. We hereby report the first known case of ocular injury caused by a tarantula in China and observed by anterior segment optical coherence tomography (AS-OCT). CASE: A 22-year-old girl was referred to our hospital with one-week history of red and irritated left eye after she grabbed her molting Chilean Rose Tarantula. Her best-corrected visual acuity was 20/20 on both eyes. Her left eyelid was slightly red and edema. Slit-lamp examination found that more than a dozen of microscopic barbed hairs embedded into the cornea. AS-OCT showed that barbed hairs embedded in the cornea in different direction and the length of the hairs ranged from 173µm to 395µm. The anterior chamber was quiet with normal fundus and intraocular pressure. Topical steroid treatment was prescribed and the response was good. No corneal opacity or intraocular inflammation was observed after topical steroid treatment for one month. CONCLUSIONS: As exotic pets become more and more popular, the importance of wearing ocular protection when handling tarantulas should be emphasized when they are sold. Tarantulas are unsuitable pet for children. When a patient presents with an unusual red eye, pet-keeping history, spiders included, should be asked.

[Complex treatment results in a congenital glaucoma patient (case report)]. / Rezul'taty kompleksnogo lecheniia patsienta s vrozhdennoĭ glaukomoĭ (klinicheskiĭ sluchaĭ).

Early diagnosis of congenital glaucoma allows surgery to be performed at the stage of reversible glaucomatous alterations of the optic disc and retina. In primary congenital glaucoma, the main reason for visual acuity reduction following surgical stabilization of the intraocular pressure are corneal changes. These include an increased corneal diameter, Haab's striae, areas of thickening and a greater posterior elevation. The resultant irregular astigmatism leads to amblyopia and a marked decrease in visual acuity. Active pleoptic treatment started from a very early age in children operated on for compensated congenital glaucoma provides them an opportunity to achieve high visual acuity and full rehabilitation.

Optical coherence tomography analysis of hydrofluoric acid decontamination of human cornea by mannitol solution.

PURPOSE: To evaluate the efficacy of mannitol solution as a decontamination agent on the chemical burn of the human corneas. METHODS: Eight donor corneas from an eye bank were exposed to 25µl of 2.5% hydrofluoric acid (HF) solution on a filter paper for 20s. Three eyes were rinsed with 1000ml of mannitol 20% for 15min immediately after removal of the filter paper, 3 other were rinsed with sodium chloride (NaCl) 0.9% (1000ml for 15min) and two eyes were not rinsed. Microstructural changes were monitored in the time domain by optical coherence tomography (OCT) imaging for 75min. RESULTS: NaCl reduced the penetration depth to approximately half the thickness of the cornea at 15min; scattering within the anterior cornea was higher than that for the unrinsed eye. With mannitol, no increased scattering was observed in the posterior part of the corneal stroma within a time period of 1h after rinsing. OCT images revealed low-scattering intensity within the anterior stroma at the end of the rinsing period. CONCLUSION: In eye bank human corneas, mannitol proved to be an efficient agent to decontaminate HF burn.

Anesthesia for Traumatic Diaphragmatic Hernia Associated with Corneal Laceration.

BACKGROUND Diaphragmatic rupture can be seen in up to 5% of car accidents, and 80%-100% of diaphragmatic hernias are associated with other vital organ injuries. Brain, pelvis, long bones, liver, spleen, and aorta are some other organs that can be severely damaged and need different anesthetic managements. CASE REPORT A 37-year-old male victim of a head-on collision who was suffering diaphragmatic rupture and corneal laceration was prepared for an emergency operation 11 hours after the car accident. Gastric decompression, pre-oxygenation, rapid sequence induction with succinylcholine, immediate use of non-depolarizing muscle relaxant, and mechanical ventilation with low tidal volume after intubation were used in anesthetic management of the patient. CONCLUSIONS Because of the high prevalence of coexisting pathologies with traumatic diaphragmatic hernia, anesthetic management must be tailored to the associated pathologies.

Change of Optical Intensity during Healing Process of Corneal Wound on Anterior Segment Optical Coherence Tomography.

The purpose of this study is to investigate the process of corneal wound healing after penetrating injury with the change in optical intensity on anterior segment optical coherence tomography (AS-OCT) and to investigate factors associated with severity of corneal scar. Forty-seven eyes from 47 patients with repaired corneal laceration were included. AS-OCT was performed on 1day, 1week, 1, 3 and 6 months after primary repair. Internal aberrations of wound edges were observed on AS-OCT images. Parameters including height of steps, width of gaps, maximal corneal thickness, area and optical intensity of corneal wound/scar were measured. The relationship between the parameters at day 1 and the optical intensity at 6 months were analyzed. The results showed that optical intensity of corneal wound/scar increased from 124.1 ± 18.8 on day 1 postoperatively to 129.3 ± 18.7, 134.2 ± 23.4, 139.7 ± 26.5, 148.2 ± 26.4 at 1 week, 1 month, 3 months and 6 months postoperatively. Height of steps at 1 day after surgery was the only factor identified as correlated with optical intensity of corneal scar at 6 months (beta = 0.34, p = 0.024). The increase of optical intensity represents the process of fibrosis of corneal wound healing. Higher step after suturing is associated with more severity of corneal scar at last.