[Keratoplasty in the management of Terrien's marginal degeneration].

OBJECTIVE: To evaluate the efficacy and safety of keratoplasty combined with corneal foci resection in the treatment of Terrien's marginal degeneration (TMD). METHODS: In this nonrandomized retrospective case series, the records of 48 eyes from 40 patients with TMD who received keratoplasty from January 1995 to December 2005 in Zhongshan Ophthalmic Center were reviewed retrospectively. Orbscan topography examination was undertaken in 8 eyes of 8 patients and the refractive error of 9 eyes from 9 patients was tested before and after the operation. RESULTS: The mean age of the patients was (30 +/- 6) years old. The mean follow up period was (7 +/- 6) years. It took (3 +/- 1) months postoperatively to obtain a stable visual acuity. Before operation, the naked eye and best corrected visual acuity (VA) (Q25,Q75) were (0.05,0.4), and (0.1,0.5), respectively, while improved to (0.2,0.6) and (0.4,0.7) after operation, respectively (Z = 4.63, 3.85, both P<0.01). VA was improved in 39 eyes (81.3%), remained at the same level in 4 eyes (8.3%), decreased 1-2 lines in 3 eyes (6.3%), and decreased more than 2 lines in 2 eyes (4.1%) after the operation. The median spherical diopter and cylinder diopter were (-2.00 D, -8.50 D) and (2.50 D,12.00 D) before operation, while decreased to ( -1.25 D, -4.75 D) and (0.75 D, 4.25 D) after operation (Z= 2. 49, 2.54, P = 0.01, 0.01). The improvement in Sim K's astigmatism, astigmatism in 3 mm zone and mean power in 3 mm and 5 mm zone were reduced statistically significant after the operation (P <0.05); with the exception of astigmatism in the 5 mm zone, which was not reduced significantly after the operation (Z = 1.86, P = 0.06) . The operative complications included corneal perforation during operation in 5 eyes (10.4%), hydrops between graft and recipient interface in 8 eyes (16.7%), epithelial in-growth in 4 eyes (8.3%), choroidal detachment in 1 eye (2.1%), graft rejection in 7 eyes (14.6%), and recurrence in 3 eyes (6.3%). Secondary surgery was required in 5 eyes (10.4%) for interface hydrops, epithelial in-growth and recurrence of TMD. CONCLUSIONS: Keratoplasty combined with foci resection is effective and safe in the treatment of TMD. This procedure can preserve and improve the visual activity.

[Preliminary clinical study of sutureless, small-incision deep lamellar endothelial keratoplasty surgery].

OBJECTIVE: To investigate the surgical procedure, clinical efficacy, and the prevention and management of complications of sutureless, small-incision deep lamellar endothelial keratoplasty (DLEK). METHODS: Nine patients (nine eyes) with bullous keratopathy underwent sutureless, small-incision DLEK surgery, six of them was combined with anterior vitrectomy. Visual acuity, graft clearance, corneal curvature, astigmatism and endothelial cell density (ECD) were observed over a 3 - 5 month follow-up period. RESULTS: All grafts remained transparent, and six eyes had improved visual acuity. After the surgery, mean corneal curvature was (43.96 +/- 3.38) D. Mean corneal astigmatism was (3.32 +/- 1.20) diopter (D). Mean ECD was (2124 +/- 278) cells/mm(2). No severe complications occurred. CONCLUSION: Sutureless, small-incision DLEK, as compared with penetrating keratoplasty (PKP) and microkeratome-associated deep lamellar endothelial keratoplasty, has more advantages and is expected to be the initial surgical treatment for bullous keratopathy.

[Clinical observation of wound dehiscence after penetrating keratoplasty].

OBJECTIVE: To investigate the treatment of wound dehiscence after penetrating keratoplasty and to evaluate the influence of this complication on visual outcome. METHODS: A retrospective analysis of 32 patients with wound dehiscence that undergone penetrating keratoplasty in Zhongshan Ophthalmic Center from July 1997 to June 2003 was performed. All involved eyes were undergone wound repair with or without iris excision, lensectomy, intraocular lens removal, anterior vitrectomy and stage I or stage II pars plana vitrectomy with gas or silicone oil tamponade according to variable extents of host-graft wound dehiscence in individual patient. Visual outcome, transparency of graft, intraocular pressure and structure integrity of ocular posterior segment were followed-up for 6-18 months in details. These data were used to summarize the specific characteristics of this type of ocular trauma. RESULTS: Surgical outcomes were recorded as the following: 24 eyeballs were rescued, but eight of them developed phthisis bulbi. Broken or loose sutures of eyes were found in eight cases. Six cases achieved better visual acuity, all of which maintained clear grafts with normal intraocular pressure, and no vitreous hemorrhage or choroidal/retinal detachment occurred. In 14 eyes with wound dehiscence of 1/4-1/2 circle, eight cases ended with decreased visual acuity, 11 with grafts opacities, five with abnormal intraocular pressure (above or below the normal range). In eight eyes with wound dehiscence of 1/2-3/4 circle, seven cases got decreased visual acuity, five with graft opacities, seven with abnormal intraocular pressure, four with vitreous hemorrhage, and four developing choroidal/retinal detachment. In the two eyes with wound dehiscence over 3/4 circle, both resulted in graft opacities with no light perception. Vitreous hemorrhage, choroidal/retinal detachment as well as phthisis bulbi occurred due to low intraocular pressure. CONCLUSIONS: After penetrating keratoplasty, the wounds of corneal graft show tectonic instability and poor resistance to tension. Traumatic wound dehiscence after penetrating keratoplasty often complicate with intraocular content herniation, vitreous hemorrhage, and choroidal/retinal detachment. Usually, this kind of trauma is from severe injuries and prognosis is worse than the common ocular trauma.

[Management of corneo-conjunctival malignant melanoma with "no touch technique" surgical excision and corneoscleral lamellar keratoplasty].

OBJECTIVE: To study the management of "no touch technique" surgical excision and corneoscleral lamellar keratoplasty in the treatment of corneo-conjunctival malignant melanoma. METHODS: Surgical excision for corneo-conjunctival malignant melanoma in six cases, from October 1989 to January 2004 in Zhongshan Ophthalmic Center, were performed. The entire tumors were removed in one piece without touching the tumor (no touch technique). The incision was outlined 4-6 mm outside the pigmented conjunctival mass, and 2 mm outside the corneal component. Dissecting deep enough without any tumor cell left to yield a tumor-free bed. After surgical incision, the host eyeball defect was covered with partial or total corneoscleral lamellar graft from fresh donor, and the conjunctiva defect was covered with or without amniotic membrane transplantation. All the patients were followed up to 6 months. RESULTS: The tumors in the remaining conjunctival margins were completely removed by local dissection combined with cryotherapy in the six cases. Three cases were treated with partial corneoscleral lamellar keratoplasty, two cases with total corneoscleral lamellar keratoplasty and one case with total corneoscleral lamellar keratoplasty plus amniotic membrane transplantation. All cases were subsequently treated with 0.01% thiotepa eyedrops and supplemental dacarbazine chemotherapy. At the average 43.5 months follow-up time (14.6 years to 6 months), no evidences of local recurrence of malignant melanoma or distant metastasis were observed. CONCLUSION: The clinical study suggests that using surgical excision of "no touch technique" to remove tumor in whole piece with corneoscleral lamellar keratoplasty is effective in the treatment of corneo-conjunctival malignant melanoma.

[The eyelid reconstruction in situ with allograft acellular dermal matrix].

OBJECTIVE: To explore the clinical value of allograft acellular dermal matrix in the treatment of eyelid defects. METHODS: From November 2001 to November 2002, 10 patients (8 male and 2 female; age varied from 14 to 47) with 11 eyelids were treated by eyelid reconstruction in situ with implantation of 1 mm thick allograft acellular dermal matrix. In 11 eyelids with defects, 2 was totally defect, 8 was 2/3 defect, 1 was 1/3 defect. In these 10 patients, 9 were injured and 1 was congenital. These defective eyelids included 8 upper lids, 1 lower lid and 1 case with both upper and lower lids. The average follow-up time was 8 months. RESULTS: In the follow-up periods, the inflammation of the eyelid was slight and no implants shedding or infection happened postoperatively. The conjunctiva grew well on the surface of the acellular dermal matrix. Histology examination showed neovascularization and presence of fibroblasts in the acellular dermal matrix 6 months after the operation. By the end of the follow up period, the results were excellent in 8 eyelids, good in 2 eyelids and improved in 1 eyelid. The efficacy rate of this treatment was 91%. CONCLUSIONS: Acellular dermal matrix can be used as a substitute of the tarsus in supporting the eyelid, it invokes little immunological and inflammatory reaction, and therefore, it can act as a biological scaffold to guide the growth of collagen and neovascularization.

[A clinical study of amniotic membrane transplantation for severe eye burns at the acute stage].

OBJECTIVE: To investigate the possibility of ocular surface reconstruction with amniotic membrane in the acute stage of burn injury, to compare the results using fresh and preserved amniotic membranes and to evaluate the surgical methods and their effects. METHODS: Consecutive patients of whole corneal burn above degree III with complete destruction of the limbus were divided into two groups to receive amniotic membrane transplantation (8 eyes of 8 patients with fresh amnion, 12 eyes of 11 patients with preserved one) or lamellar keratoplasty (24 eyes of 22 patients). The follow-up period was 12 to 26 months with an average of (15 +/- 2) months. RESULTS: The ocular surface became stabilized after the transplantation of amniotic membrane. In eyes treated with fresh amniotic membrane, the corneal surface was epithelized immediately. In eyes treated with preserved amniotic membrane, the corneal surface was epithelized only after 2 - 3 weeks. Lamellar keratoplasty was performed in 3 of 12 eyes with preserved amnion transplantation because the amnion was dissolved due to persistent epithelial defects. Amnions were absorbed with time and superficial neovascularization followed in the corneal surfaces. Seven of eight transplanted fresh amnions were absorbed within 2 to 8 months [mean time (4.3 +/- 0.8) months], and 10 of 12 preserved amnions were absorbed within 1 to 3 months [mean time (2.0 +/- 0.3) months]. The difference was statistically significant (t = 4.22, P < 0.01). The conjunctival surface was successfully reconstructed with amniotic membrane at the acute stage of burn injury. Moderate symblepharon occurred in one case only. Corneal dissolution never occurred in all patients who received lamellar keratoplasty, but recurrent erosion of corneal epithelium occurred in the grafts and corneal neovasularization developed eventually. Corneal graft had to be performed again on four eyes and symblapharonplasty had to be performed on seven eyes. Mild to medium symblepharon was observed in 5 of 24 eyes received lamellar keratoplasty. Visual acuity could be maintained at hand movement in eyes treated with amniotic membrane transplantation without secondary glaucoma and cataract. Visual acuity was figure counting in most cases with lamellar keratoplasty. CONCLUSIONS: Amniotic membrane transplantation (especially using a fresh membrane) can effectively reduce the inflammation of the cornea at the acute stage of burn injury, can prevent corneal ulcer and perforation and can make the stabilization process faster. It can also decrease corneal neovascularization as well as establish better conditions for successful keratoplasty.

[Long-term results of amniotic membrane transplantation for conjunctival surface reconstruction].

OBJECTIVE: To investigate the long-term results of amniotic membrane transplantation (AMT) for conjunctival surface reconstruction after symblepharon resection and analysis the related factors. METHODS: Fifty-one cases (55 eyes) with symblepharon due to eye burns (chemical or heat) or Stevens-Johnson syndrome were selected for symblepharon resection and AMT. Ten eyes were performed within 1 year and twenty-three eyes in 1.0 to 8.0 years after chemical eye burns. RESULTS: Observation time varied from 26.0 to 30.0 months [mean value (27.4 +/- 2.6) months]. No necrosis and ulceration were found in all amnion grafts at the early stage after transplantation. Deep conjunctival fornix and free of eye movement were obtained in 56.4% (31/55) of those eyes received surgery. Slight symblepharon recurrence and limited eye movement restrict were revealed in 16.4% of them (9/55), Fifteen eyes of them (27.3%) shown moderate recurrence of symblepharon. The effects of AMT for those patients with different degree of symblepharon had significant difference statistically (Pearson Chi-Square, P = 0.000). The same results were observed between those patients who were performed in different time after chemical eye burns (Likelihood Ratio, P = 0.039) and with different severity of dry eye (Pearson Chi-Square, P = 0.000). CONCLUSIONS: Amniotic membrane can be used to reconstruct ocular surface effectively, but multiple surgeries may be needed. These microenvironments such as symblepharon severity, dry eye, and whether remained partial healthy conjunctiva in the affected eyes before surgery will influence the long-term results of AMT for conjunctival surface reconstruction.

[Clinical characteristics of patients with dry eye syndrome].

OBJECTIVE: To learn the clinical characteristics of patients with dry eye syndrome. METHODS: The following items were recorded in 115 patients (229 eyes) with dry eye, including symptoms, causation, systematic diseases, slit-lamp examination, tear break-up time, basal and reflex Schirmer's test, vital staining (fluorescent and rose bangle) and meibomian gland dysfunction examination. Rheumatoid factor and auto-antibody detection were performed in Sjögren's syndrome suspected patients. RESULTS: Aqueous tear deficiency (ATD, 48.7%) ranked the most common type, followed by over-evaporation dry eye (34.8%), mixed type (13.9%) and conjunctivochalasis (3.5%). In all the causes of the dry eye, about 11.3% had Sjögren syndrome (SS). Females suffering from dry eye were more than males, especially SS. Dryness was the most common symptom (84.0%), especially in ATD patients, then followed by ocular fatigue (72.0%), foreign body sensation (64.0%) and impairment of vision (56.0%). The ocular irritation was more severe in meibomain gland dysfunction (MGD) patients than in ATD patients. Among the results of tear break-up time (BUT), rose bangle (Rb) staining and fluorescent (Fl) staining in all types of dry eye, significant relationship was found among them, especially between Rb and Fl score (r = 0.612, P = 0.000). SS patients had much more severe abnormality in all the four signs than non-SS aqueous tear deficiency (NSTD) and MGD patients. However, in the comparisons of BUT, Rb and Fl between NSTD and MGD patients, there were no significant differences. CONCLUSION: Symptoms combined with examinations of BUT, Schirmer's test, Fl and Rb staining and meibomian gland function are the necessary means to diagnose most of the dry eye patients.