Risk factors associated with retinal hemorrhage in suspected abusive head trauma.

PURPOSE: To determine risk factors associated with retinal hemorrhage (RH) in pediatric abusive head trauma (AHT) suspects. METHODS: Records of children aged 0-3 years hospitalized for suspected AHT from January 2007 to November 2011 were retrospectively reviewed in this case-control study. Children were classified into case and control groups based on RH presence. Medical history, presenting symptoms, reasons, and characteristics of injury were recorded. Logistic regression analysis was performed to identify risk factors. RESULTS: A total of 168 children (104 males) were included. Of these, 103 were classified as cases and 65 as controls. The mean age (with standard deviation) was 9.3 ± 8.3 months (range, 1 day-36 months). Of the 103 cases, 22 (21%) had subretinal hemorrhage, 9 (9%) had retinoschisis, and 1 (1%) had vitreous hemorrhage. Children presenting with lethargy or altered mental status (P < 0.0001), subdural hemorrhage (P < 0.0001), and other radiologic findings (eg, cerebral ischemia, diffuse axonal injury, hydrocephalus, or solid organ injury; P = 0.01546) were likely to have RH. All 23 children with skull or nonskull fracture without intracranial hemorrhage did not have RH (P < 0.0001 both categories). CONCLUSIONS: Retinal hemorrhages were almost never found in the absence of intracranial hemorrhage and not found in the setting of fracture without intracranial hemorrhage.

One-year outcomes in eyes remaining phakic after Descemet membrane endothelial keratoplasty.

PURPOSE: To assess 1-year outcomes in patients remaining phakic after Descemet membrane endothelial keratoplasty (DMEK). SETTING: Private clinic, Indianapolis, Indiana, USA. DESIGN: Interventional case series. METHODS: Data on consecutive DMEK cases with retention of the crystalline lens were reviewed. The outcome measures were development or progression of postoperative lens opacity, performance of cataract extraction, endothelial cell loss, and corrected distance visual acuity (CDVA) at 1 year. The rate of and risk factors for cataract formation and extraction were analyzed using multivariate proportional hazards modeling and Kaplan-Meier survival analysis. RESULTS: Of the 49 eyes, 15 (31%) had trace nuclear sclerosis and 34 (69%) had clear lenses preoperatively. The median patient age was 50 years. Forty-eight eyes (98%) were treated for Fuchs dystrophy. The median follow-up after DMEK was 12 months. All grafts cleared and remained clear. Cataract progression occurred postoperatively in 37 eyes (76%); cataract surgery was performed in 16 eyes (33%). Patients older than 50 years had a higher risk for cataract progression after DMEK (P=.0094). The median endothelial cell loss was 25% within the first year. The median CDVA was 20/20 at 1 year. CONCLUSIONS: Descemet membrane endothelial keratoplasty accelerated the natural rate of cataract formation, consistent with data on other types of corneal transplantation including penetrating keratoplasty and Descemet-stripping automated endothelial keratoplasty. Patients older than 50 years had higher risk for cataract progression than younger patients. The majority of patients achieved 20/20 CDVA.

A Technique to Rescue Keratoprosthesis Melts.

PURPOSE: To describe a technique to completely replace the donor corneal carrier of an existing type 1 Boston keratoprosthesis (KPro) that preserves the hardware intact. METHODS: Two eyes with sterile corneal melts around the KPro stem underwent a complete exchange of the donor corneal carrier. Donor corneas were prepared in the usual fashion for KPro and were then left uncovered to dehydrate. Meanwhile, the melted corneas were excised in a manner similar to that for failed penetrating grafts and uncollared from the KPro. The new donors were then sufficiently thinned to slide between the back and front plates; however, to clear the 5.0-mm KPro front plate flange, the central 3.0-mm opening in the replacement donor corneas was first enlarged by means of 2 paired sub-1.0-mm radial relaxing incisions placed 180 degrees apart. Once positioned, the new donor carriers were rehydrated to seal the space between the back and front plates. RESULTS: The full-thickness corneal carrier was successfully replaced in both cases. In 1 case, scarring of the back plate holes caused the plate to behave like an intact Descemet membrane during deep anterior lamellar keratoplasty. CONCLUSIONS: When an otherwise functional KPro is jeopardized because of disorders of the donor corneal carrier, it can be advantageous to selectively replace the carrier and thus salvage the original KPro. We describe such a rescue technique, which permits the exchange of the corneal carrier without disassembling the KPro.

Effect of donor preparation-to-use times on Descemet membrane endothelial keratoplasty outcomes.

PURPOSE: To report the effect of varying donor preparation-to-use times on outcomes of Descemet membrane endothelial keratoplasty (DMEK). METHODS: Prospective interventional series. DMEK donor tissues prepared at a single center on the day of surgery (group 0), 1 day before the surgery (group 1), or 2 days before the surgery (group 2) were transplanted into 361 eyes for Fuchs dystrophy, pseudophakic bullous keratopathy, or graft failure, with or without combined cataract surgery. When prepared ahead, the donor tissue was stored in refrigerated corneal storage solution until use. Primary outcome measures were air reinjection rate, primary failure rate, and endothelial cell loss. RESULTS: Donor and recipient characteristics did not differ significantly between the groups. In groups 0, 1, and 2, the rate of failure to clear was 1.5%, 1.9%, and 2.8%, respectively (P = 0.78), and the rebubbling rate was 15%, 13%, and 14%, respectively, in the grafts that cleared successfully (P = 0.92). Median endothelial cell loss at 3 months was 28%, 29%, and 29%, respectively (P = 0.56). CONCLUSIONS: Having DMEK donor tissue prepared in advance can be logistically advantageous. Tissue preparation in advance with storage for 1 or 2 days in corneal storage solution at 4°C was not associated with any significant difference in the primary failure rate, air reinjection rate, or endothelial cell loss compared with the same-day preparation. The maximum allowable preparation-to-use time and the effects, if any, of different storage media or transportation from off-site locations have yet to be determined for precut DMEK tissue.

Handheld slit beam techniques to facilitate DMEK and DALK.

PURPOSE: To describe techniques for using a handheld slit beam to identify the position of detached Descemet membrane in Descemet membrane endothelial keratoplasty (DMEK) and deep anterior lamellar keratoplasty (DALK). METHODS: The Eidolon model 510L handheld slit lamp (Eidolon Optical LLC) was used during DMEK cases to identify the orientation of inserted grafts in the anterior chamber before unrolling. In DALK, the beam was used to identify the presence of a big bubble. RESULTS: By using the slit beam technique, a DMEK surgeon can know which side of the partially scrolled graft is endothelium and decide whether to turn it over or inject an air bubble under it. In DALK, the technique allows the surgeon to verify if a big bubble has formed while looking through moderately opacified stroma after air injections. CONCLUSIONS: These slit beam techniques should prove useful to lamellar keratoplasty surgeons and improve patient outcomes.