Suture Fixation to Reduce Graft Detachment in Descemet Stripping Endothelial Keratoplasty.

PURPOSE: The aim of this study was to report the outcomes of graft fixation using interrupted, full-thickness sutures on graft detachment after Descemet stripping endothelial keratoplasty (DSEK). METHODS: All DSEK procedures performed at Mayo Clinic, Rochester, MN, from 2015 through 2022 were retrospectively reviewed. Risk factors for graft detachment were defined as previous incisional glaucoma surgery, previous penetrating keratoplasty, or absence of the normal lens-capsule barrier. Cases were categorized into sutured, high-risk grafts; unsutured, high-risk grafts; and unsutured, low-risk grafts. The primary outcome was graft detachment, and secondary outcomes were early graft failure and graft clarity at 12 months after surgery. RESULTS: Demographics between the high-risk groups were similar for sex and age at the time of surgery. Graft detachment occurred in 4 of 97 sutured, high-risk eyes (4.1%) and 24 of 119 unsutured high-risk eyes (20.2%) ( P = 0.002). In comparison, graft detachment occurred in 18 of 181 unsutured low-risk eyes (9.9%). The incidence of early graft failure was 2.1%, 5.0%, and 3.3% and late graft failure by 12 months was 9.8%, 12.8%, and 4.2%, respectively. CONCLUSIONS: In eyes with high-risk factors for graft detachment, suture fixation of the graft in DSEK decreased graft detachment to a rate at least as low as that in low-risk eyes.

Risk Factors for Fibrous Ingrowth in Eyes Requiring Primary Keratoplasty.

PURPOSE: The aim of this study was to define risks for corneal transplantation associated with fibrous ingrowth among first-time transplant recipients. METHODS: We performed a retrospective case-control study of patients with a histopathologic diagnosis of fibrous ingrowth between 2002 and 2019. Patients with fibrous ingrowth from a first corneal specimen were included. Those with incomplete records were excluded. A 1:2 case-control ratio was used. Controls were matched using surgical indication, surgery year, transplantation method, sex, and age. RESULTS: Seventy-eight eyes (76 patients) were included and matched with 160 control eyes. The incidence of fibrous ingrowth found on a first corneal transplant was 0.6% per year. The most common keratoplasty indications were pseudophakic corneal edema (n = 25, 32%) and aphakic corneal edema (n = 15, 19%). Cases were more likely to have a history of ocular trauma (odds ratio [OR], 2.94; 95% CI, 1.30-6.30; P = 0.007), uveitis (OR, 2.73; 95% CI, 1.12-6.63; P = 0.022), retinal detachment or previous retinal surgery (OR, 2.40; 95% CI, 1.34-4.30; P = 0.003), glaucoma tube-shunt surgery (OR, 2.70; 95% CI, 1.29-5.65; P = 0.007), aphakia (OR, 3.02; 95% CI, 1.61-5.67; P = 0.0004), or iris derangement (OR, 10.52; 95% CI, 5.45-20.30; P <0.0001). A multivariate logistic regression model using iris derangement, history of ocular trauma, history of uveitis, and history of cataract surgery demonstrated 81% sensitivity and 66% specificity in predicting presence of fibrous ingrowth. CONCLUSIONS: A history of ocular trauma, uveitis, retinal detachment or previous retinal surgery, glaucoma tube-shunt surgery, aphakia, and iris derangement are risks for detecting fibrous ingrowth among first-time keratoplasty recipients. Patients with these conditions should be monitored closely for corneal decompensation.

Population-Based Evaluation of Indirect Signs of Increased Intracranial Pressure.

BACKGROUND: The Mayo Clinic Study of Aging (MCSA) is a unique prospective study that systematically evaluates the normal aging population and includes many participants undergoing both MRI and lumbar puncture (LP). Using MCSA date, we aimed to determine the prevalence of indirect signs of raised intracranial pressure (ICP) on MRI and whether these correlate with LP opening pressure (OP). This is a large-scale study that evaluates how often indirect signs of increased ICP occur in a normal population. METHODS: MCSA participants who had an MRI within 3 months of an LP with recorded OP were included in the study. MRIs were reviewed for indirect signs of raised ICP, including pituitary to sella (P/S) ratio, cerebellar tonsillar ectopia, and optic nerve sheath diameter (ONSD). These signs were evaluated for correlations with OP and influences from body mass index (BMI) and obstructive sleep apnea (OSA). RESULTS: Five hundred ninety-seven MCSA patients were identified who underwent both LP and MRI. Two hundred sixty (43.6%) were women. The median age was 70.7 years (range 32.6-92.7). Median OP was 152 mm H2O (range 60-314 mm H2O), with 91 (15.2%) participants having an OP ≥ 200 mm H2O. Empty or partially empty sella was seen in 81 (12.8%) of the cohort. The P/S ratio decreased with increasing OP (r = -0.3, P < 0.001). There was a weak correlation between OP and average ONSD (r = 0.184, P = 0.01), which was no longer significant when accounting for age, gender, and BMI (partial r2 = 0.014, P = 0.097). There was no correlation between OP and cerebellar tonsillar ectopia. OSA was associated with increased ONSD (P = 0.004), but this did not remain statistically significant after accounting for age, gender, and BMI (P = 0.085). CONCLUSION: Smaller pituitary gland size correlated with increasing OP. This suggests that ICP is a continuum with some normal individuals demonstrating asymptomatic radiologic signs of raised ICP.

Myopic shift after Salzmann nodule excision.

PURPOSE: To quantify changes in manifest refractive error and mean keratometric power (Km) at 1 month and ≥12 months after Salzmann nodule excision. SETTING: Cornea service at Mayo Clinic, Rochester, MN. DESIGN: Retrospective consecutive case series. METHODS: Changes in manifest refractive error (spherical equivalent), Km, and corrected distance visual acuity (CDVA) were compared for 73 eyes of 58 patients who underwent Salzmann nodule excision. Eyes with ocular comorbidities were excluded. Comparisons between preoperative and postoperative measurements were made by using generalized estimating equation models. RESULTS: Mean patient age was 66 years, and 53 patients (91%) were female. Spherical equivalent manifest refractive error was -0.27 ± 2.66 diopters (D) before nodule excision and became more myopic (-1.10 ± 2.78 D) at 1 month after nodule excision (n = 69, P < .001) with no change at 12 months (n = 14, P = .13). A myopic shift ≥0.5 D occurred in 65% of eyes and ≥1.0 D in 36% of eyes. Km increased from 42.7 ± 2.11 D before nodule excision to 44.2 ± 1.82 D at 1 month after excision (n = 49, P < .001). CDVA improved from 0.18 ± 0.15 logMAR (Snellen equivalent 20/30) before nodule excision to 0.05 ± 0.09 logMAR (20/22, n = 69, P < .001) at 1 month after excision with no change at 12 months (n = 14, P = .73). CONCLUSIONS: In addition to known changes in cylinder, Salzmann nodule excision is associated with a myopic shift in most eyes caused by corneal steepening. Patients should be counseled about the likelihood of refractive changes, and cataract surgery should be deferred until refractive stability is achieved.

Alkali Burn Over a LASIK Flap.

PURPOSE: To describe the management and outcome of an ocular surface alkali burn in the setting of previous laser in situ keratomileusis (LASIK). METHODS: This is a case report and review of relevant literature. RESULTS: A 25-year-old man with a history of LASIK presented 4 weeks after a sodium hydroxide splash to his left eye with visual acuity of 20/60 and a nonhealing epithelial defect adjacent to sectoral inferior limbal ischemia in the setting of trichiasis from upper eyelid cicatricial entropion. After topical corticosteroids were discontinued following the repair of the entropion, the patient returned 3 days later with worsening vision and severe diffuse lamellar keratitis with the melting of the LASIK flap. After promptly lifting the flap and debriding the interface, inflammation was managed with oral, instead of topical, corticosteroids. Over several weeks, the epithelium healed, and inflammation and interface edema resolved. At 10 years of follow-up, the patient had developed a localized pseudopterygium with mild corneal neovascularization but maintained 20/20 uncorrected visual acuity. CONCLUSIONS: A chemical burn over a LASIK flap poses a challenge for managing corticosteroids, which are required to prevent diffuse lamellar keratitis but can also contribute to keratolysis beyond the first week after an alkali injury. Oral corticosteroid therapy may be beneficial in this situation, with a low threshold to lift the LASIK flap and debride the interface if inflammation occurs.

Scleral Lens Use in Neurotrophic Keratopathy: A Review of Current Concepts and Practice.

OBJECTIVE: Neurotrophic keratopathy (NK) is a rare corneal condition characterized by epitheliopathy, which is associated with reduced or absent corneal sensation. The main goal of treatment of this condition is the preservation of ocular surface integrity. Contact lenses provide a nonsurgical and reversible option to provide the necessary corneal protection. The purpose of this review was to summarize the available literature regarding the use of contact lenses in the management of NK, with particular emphasis on the use of scleral lenses. METHODS: Literature related to both soft and scleral contact lens use as treatment options for NK was reviewed. RESULTS: As of yet, randomized clinical trials have compared neither the efficacy of contact lens therapy for NK to other therapeutic alternatives nor outcomes of therapy with different contact lens modalities. However, clinical case reports and limited case series have suggested that scleral lenses may be a safe and effective treatment option for NK at any stage of the disease, preserving epithelial integrity and even improving visual function in patients with this condition. CONCLUSIONS: Scleral lenses may be effective in reducing the need for surgical intervention and improving the quality of life in patients with NK.

Diffuse Outer Layer Opacification: A Novel Finding in Patients With Autosomal Recessive Bestrophinopathy.

PURPOSE: Autosomal recessive bestrophinopathy (ARB) is a rare inherited retinal dystrophy resulted from mutations in bestrophin-1 (BEST1) which affect functioning of the retinal pigment epithelium (RPE). Descriptions of disease findings in patients with ARB to date have focused only on macular changes. In this case series, we report previously undescribed mid-peripheral retinal changes occurring in 4 patients with ARB. DESIGN: Case series. METHODS: A single-center, retrospective review of medical records from Mayo Clinic patients with ARB was performed. Imaging reviewed include fundus photography, fundus autofluorescence, spectral domain optical coherence tomography (OCT), and fluorescein angiography. Demographic information and disease progression were noted. RESULTS: 4 affected patients from 3 families were identified. All 4 patients were female, and mean age was 12.5 years (range 5-19 years). Diffuse mid-peripheral whitening was consistently noted on fundus photography. Concomitant OCT imaging demonstrated areas of hyperreflectivity in the photoreceptor outer segment layer in areas corresponding to whitening seen on fundus photography. In 1 patient who was followed for 12 years, this finding persisted. Subretinal fluid was also consistently present. Other pathologic imaging findings observed in each patient were in agreement with previous reports of ARB. CONCLUSIONS: This is the first descriptive report of pathologic findings occurred beyond the posterior pole in patients with ARB. These mid-peripheral retinal changes potentially imply that the entirety of the RPE is affected by mutations in BEST1, as also suggested by previous electro-oculogram (EOG) findings. Such implications will be important when developing treatment trials, as past trials have focused only on the posterior pole of the RPE.

Perianal Dermatitis, Its Incidence, and Patterns of Topical Therapies in a Level IV Neonatal Intensive Care Unit.

OBJECTIVE: To define the incidence of perianal dermatitis (PD) and determine the usage pattern and cost efficacy of diaper products among neonates admitted to a level IV neonatal intensive care unit (NICU) including those with a diagnosis of neonatal abstinence syndrome (NAS). METHODS: A retrospective cohort study to evaluate neonates with PD based on number of orders for Aquaphor, Bagbalm, Desitin, Flanders, or Nystatin. Various demographic and clinical parameters were recorded. Usage patterns of these five products were analyzed, and their costs estimated. Subgroup analysis was performed among infants with NAS. RESULTS: Of 1,241 admissions, 56.2% had at least one diaper product ordered during their NICU stay, while 52.6% had multiple products ordered. Only 23.0% of all neonates had appropriate documentation of PD. The most common product ordered first was Aquaphor (64.3%), followed by Desitin (19.2%). Note that 86% term NAS infants had PD compared with 28% term non-NAS infants. The estimated product cost was $14,139 over 2 years, averaging $20 per patient. CONCLUSION: Over half of NICU neonates were exposed to one or more diaper products, usually without documented PD diagnosis. Term NAS infants had three times higher incidence of PD than term non-NAS infants. The cost of diaper product use was significant, and possibly underestimated due to lack of documentation.