Atypical Presentation of Iridocorneal Endothelial Syndrome With Band Keratopathy but No Corneal Edema Managed With Descemet Membrane Endothelial Keratoplasty.

PURPOSE: To report an unusual presentation of iridocorneal endothelial (ICE) syndrome associated with band keratopathy and its management with ethylenediamine-tetraacetic acid (EDTA) chelation and Descemet membrane endothelial keratoplasty (DMEK). METHODS: A 57-year-old female patient presented with unilateral progressive painless visual impairment, corneal band keratopathy, and morphological corneal endothelial changes without corneal edema or any previous ophthalmic, medical, or family history. Routine specular and confocal microscopy imaging, as well as biomicroscopy, best-corrected visual acuity, and pachymetry measurements were performed before and after the surgical procedures. Histopathologic and immunohistochemical evaluations of the surgically excised diseased DM-endothelium were performed. RESULTS: Superficial epithelial keratectomy with EDTA chelation was performed. After an initial period of a few months of corneal clearance, the patient presented with recurrence of visually significant band keratopathy. After 1 year, she underwent retreatment with superficial epithelial keratectomy and EDTA chelation, followed by DMEK. Histopathologic and immunohistochemical analysis showed ICE syndrome. Two years after DMEK surgery, the cornea was still clear and band keratopathy had not recurred. CONCLUSIONS: To the best of our knowledge, this is the first case in the literature that reports the association of ICE syndrome with band keratopathy. As band keratopathy recurred shortly after EDTA chelation, endothelial keratoplasty (DMEK) may be indicated to successfully treat such cases.

Outcomes of Hemi-Descemet Membrane Endothelial Keratoplasty for Fuchs Endothelial Corneal Dystrophy.

PURPOSE: To report the mid-term outcomes of hemi-Descemet membrane endothelial keratoplasty (hemi-DMEK) performed for Fuchs endothelial corneal dystrophy (FECD). METHODS: In this prospective, interventional case series, we evaluated clinical outcomes of 10 eyes from 10 patients who underwent hemi-DMEK for FECD. Main outcome measures were best-corrected visual acuity (BCVA), endothelial cell density (ECD), central pachymetry, and postoperative complications. RESULTS: At 1 year postoperatively, 7/7 eyes (excluding 2 eyes with low visual potential) reached a BCVA of ≥20/40 (≥0.5), 6/7 (86%) ≥20/25 (≥0.8), 4/7 (57%) ≥20/20 (≥1.0), and 2/7 (29%) 20/17 (≥1.2). BCVA remained stable until 2 years postoperatively (P ≥ 0.05) and further improved thereafter (P < 0.05). Mean ECD decreased from 2740 (±180) cells/mm preoperatively to 850 (±300) cells/mm (n = 9) at 1 year (P ≤ 0.05) and showed an annual decrease of on average 6% to 7% thereafter (P ≥ 0.05 between consecutive follow-ups). Pachymetry decreased from preoperatively 745 (±153) µm to 533 (±63) µm (n = 9) and 527 (±35) µm (n = 8) at 1 and 3 years postoperatively, respectively. Within the first 6 postoperative months, 4/10 eyes underwent rebubbling for visually significant graft detachment. One eye received secondary circular DMEK for persistent graft detachment 1 month postoperatively; another eye developed secondary graft failure 2.5 years postoperatively, and 1 eye was suspected for an allograft reaction 1.5 years postoperatively. CONCLUSIONS: Hemi-DMEK may render visual outcomes comparable to those achieved by conventional DMEK. Despite low ECD counts by 6 months, ECD levels remain fairly stable thereafter. Hence, hemi-DMEK may become a potential alternative technique for treatment of FECD while increasing the yield of the endothelial tissue pool.

Quarter-Descemet membrane endothelial keratoplasty (Quarter-DMEK) for Fuchs endothelial corneal dystrophy: 6 months clinical outcome.

BACKGROUND/AIM: To assess the clinical outcome of the first series of Quarter-Descemet membrane endothelial keratoplasty (Quarter-DMEK), a potential hybrid technique between 'descemetorhexis only' and conventional, circular DMEK. METHODS: Prospective interventional case series at a tertiary referral centre. Twelve eyes of 12 patients with central Fuchs endothelial corneal dystrophy underwent Quarter-DMEK, that is, transplantation of one quadrant of a full-diameter DMEK graft, and were evaluated for best-corrected visual acuity (BCVA), endothelial cell density (ECD) and complications up to 6 months postoperatively. RESULTS: At 6 months postoperatively, all eyes reached a BCVA of ≥20/40 (≥0.5), 11/12 (92%) of ≥20/25 (≥0.8) and 6/12 (50%) of ≥20/20 (≥1.0). Mean central ECD decreased from 2867 (±161) cells/mm2 before to 1255 (±514) cells/mm2 at 1 month, 1058 (±455) cells/mm2 at 3 months and 968 (±427) cells/mm2 at 6 months after surgery. Rebubbling was performed in 4/12 eyes (33%) within the first two months. CONCLUSIONS: Quarter-DMEK may be a feasible procedure that allows for visual outcomes similar to conventional, circular DMEK. The relatively large drop in ECD within the first month may have resulted from more extensive endothelial cell migration and/or measurement error (at the graft edges). If longer-term outcomes would resemble those of conventional DMEK, Quarter-DMEK may potentially quadruple the availability of endothelial grafts.

Dark Endothelial Spots After Descemet Membrane Endothelial Keratoplasty May Appear as Recurrent Fuchs Dystrophy or Herald Graft Failure or Rejection.

PURPOSE: To evaluate the clinical significance of dark spots in the donor endothelial cell layer as observed with specular microscopy, in patients who underwent Descemet membrane endothelial keratoplasty (DMEK) for Fuchs endothelial dystrophy (FED). METHODS: Specular microscopy images of 83 consecutive eyes up to 7 years after DMEK were retrospectively reviewed in a masked fashion for the presence of dark spots and morphologic changes in the endothelial cell layer and processed for endothelial cell density (ECD) measurements. RESULTS: A normal endothelial cell layer was found in 52/83 eyes (62.7%) (group 0). In the remaining 31/83 eyes, various dark discolorations with or without altered endothelial cell morphology were categorized into 4 groups. Dark spots were classified as artifacts in 10/83 (12.0%) eyes (group I) and as "superimposed" dots in 10/83 (12.0%) eyes (group II), that is, optical irregularities slightly anterior to a healthy endothelial cell layer. In 11/83 (13.3%) eyes, endothelial stress was characterized by dark grayish discolorations and/or nuclear activation (group III). Most of the latter eyes also had a significant ECD decrease; 3 of these eyes later developed secondary graft failure, of which one was preceded by allograft rejection. None of the eyes showed recurrent guttae typical for FED (group IV). CONCLUSIONS: Dark endothelial spots after DMEK for FED may not represent a recurrent disease, but tissue irregularities just anterior to the graft. However, if associated with changes in endothelial cell morphology, nuclear activation and/or ECD decrease, dark discolorations may reflect "cellular stress" heralding secondary graft failure or (subclinical) allograft rejection.

RITONAVIR-ASSOCIATED TOXICITY MIMICKING RETINITIS PIGMENTOSA IN AN HIV-INFECTED PATIENT ON HIGHLY ACTIVE ANTIRETROVIRAL THERAPY.

PURPOSE: To report ritonavir-associated retinal pigment epithelium toxicity in a patient infected with the HIV on highly active antiretroviral therapy including ritonavir. METHODS: Retrospective single case report. The authors describe a case of gradual onset of blurry vision in both eyes in an HIV-positive male. Visual acuity, clinical examination findings, and functional testing (electroretinogram and Goldmann perimetry) were reviewed. Diagnostic imaging, including fundus photography, spectral domain optical coherence tomography, fluorescein angiography, and fundus autofluorescence were assessed. RESULTS: 59-year-old HIV-infected male, treated with ritonavir for eight years, presented with a history of decreased night vision and peripheral field loss. Ophthalmologic examination confirmed the diagnosis of retinal toxicity. Goldmann perimetry showed areas of central and para-central scotomas. Electroretinograms demonstrated mild to moderate photoreceptor dysfunction. Fundus examination revealed a diffuse pattern of retinal pigment epithelium mottling in both eyes. Spectral domain optical coherence tomography confirmed the presence of choroidal thinning, whereas fundus autofluorescence showed mottled hypoautofluorescence. CONCLUSION: Although ritonavir-associated retinal toxicity is clinically uncommon, the clinical features of our findings support this diagnosis. Consideration of highly active antiretroviral therapy-associated retinal toxicity should be given to the differential diagnosis in HIV-positive patients with retinopathy of unclear etiology. This report also highlights the need for constant monitoring of patients using the ritonavir for early detection of possible retinal toxicity.

Real-world treatment of diabetic macular oedema: a comparison of combined ranibizumab plus macular LASER with macular LASER monotherapy.

OBJECTIVE: To study real world outcomes of ranibizumab (Lucentis) intravitreal injection in diabetic macular oedema (DMO). SUBJECTS AND METHODS: We included 100 patients with DMO. Those who had optical coherence tomography central retinal thickness (CRT) of 400µm or more (Group 1) underwent combination treatment with ranibizumab and macular LASER, while those with CRT less than 400µm (Group 2) had LASER monotherapy. The primary outcome measure was change in best corrected visual acuity (BCVA) from baseline. Secondary outcomes were change of CRT from baseline, the number of intravitreal injections in group one during the first and second year of follow-up and the proportion of LASER sessions in both groups at 2 years follow-up. Patients' lipid profile was compared to the presence and extent of macular hard exudates, quantified using masked readers and image analysis software. RESULTS: Group 1 showed better outcomes in terms of BCVA and CRT compared to Group 2 during the two-year follow-up period. The mean number of ranibizumab intravitreal injections in Group 1 was reduced from 3.86 (standard deviation±1.37) in the first year to 2.02 in the second year. At 2 years, Group 1 had a higher proportion of individuals that had undergone 3 macular LASER treatments (4% Group 1, 28% Group 2). The presence of hard exudates was associated with higher total cholesterol (P=0.004 and P=0.041 group 1 and 2 respectively) and with higher low density lipoprotein (LDL) cholesterol (P=0.01 and P=0.045 respectively). The size of hard exudates was associated with higher total cholesterol (P=0.02 and P=0.03 respectively) and with higher LDL cholesterol (P=0.003 and P=0.01 respectively). Neither high density lipoprotein (HDL) cholesterol, nor triglycerides were related to the presence or size of hard exudates. No serious adverse events were attributed to either LASER or ranibizumab. CONCLUSIONS: Combination treatment of intravitreal ranibizumab injections and macular LASER appears safe and effective over two years. The need for injection declines over time. There is an association between higher levels of serum total and LDL cholesterol and the presence and the extent of hard exudates.

Intravitreal aflibercept (A-IVI) for the treatment of neovascular age-related macular degeneration (nv-AMD): one year experience.

OBJECTIVE: To report the anatomical and functional results of intravitreal injections of aflibercept (Eylea) (A-IVI) for the treatment of naïve eyes with neovascular age-related macular degeneration (nv-AMD). SUBJECTS AND METHODS: This retrospective, one-center, non-comparative chart review included 26 treatment naïve eyes with nv-AMD of 26 patients (14 male) with a mean age of 80.5 (range 63-91) who had a complete follow-up of 14 months. The morphological analysis included spectral domain optical coherence tomography and fundus fluorescein angiography, while the functional assessment included logarithm of the minimum angle of resolution (LogMAR) best correct visual acuity (BCVA). The timing of the follow-up was: baseline, 3, 6, and 14 months. All patients received 8 A-IVI according to the protocol (first 3 consecutive monthly A-IVI, followed by bi-monthly retreatment for the first year, regardless of disease activity as per local guidelines). Statistical analysis was performed using ANOVA. Improvement of visual acuity more than 15 letters was considered as "improvement", less than 5 letters as "stable" and any letter loss as "worsening". RESULTS: Mean±standard deviation LogMAR visual acuity improved from 0.26±0.15 at presentation to 0.14±0.20 at the final follow-up of 14 months (P=0.02). BCVA was stable in 23.1%, improved in 61.5% (16 eyes) worsened in 15.4%. A mean pretreatment central macular thickness of 409µm reduced significantly to 229µm at month 14 (P<0.02). The OCT of eyes with worsened BCVA showed resolution of retinal fluid but presence of subretinal fibrosis. No adverse events were attributed to aflibercept. CONCLUSIONS: Patients who had a worsening in visual acuity were found to have longer duration of symptoms prior to treatment and presence of geographic atrophy, and/or subretinal haemorrhage and/or subretinal fibrosis at baseline. From our experience, with 14 months follow-up, A-IVI is an effective treatment for treatment naïve patients with nv-AMD. Our real world results were similar to pivotal trials.

Complications and outcomes of phacoemulsification cataract surgery complicated by anterior capsule tear.

PURPOSE: To study the results of phacoemulsification cataract surgery complicated by anterior capsule tear. DESIGN: Retrospective interventional controlled case series. METHODS: Consecutive series of eyes suffering intraoperative anterior capsule tear and others with uneventful cataract surgery at Moorfields Eye Hospital were investigated. Biometric, intraoperative, and postoperative details were recorded. The exclusion criteria were combined surgical procedures, planned manual extracapsular cataract extraction, and history of previous intraocular surgery or eye trauma. The main outcome measures were intraoperative capsule complication rates, refractive and visual outcomes, and incidence of short-term postoperative complications. Two-sided Fisher exact and paired t tests were used for categorical and continuous data, respectively. RESULTS: The study and control groups included 239 and 212 eyes, respectively. In the study group, planned phacoemulsification was converted to manual extraction in 5 cases (2%); a concurrent posterior capsule rupture occurred in 58 eyes (24%) with a rate of nuclear lens material drop in the posterior segment of 5% (11 cases). Over 11% of eyes (n = 27) underwent unplanned secondary surgical procedures. Overall, the refractive outcomes were poor in 22.4% of eyes (postoperative refraction ≥1 diopter of target), and were statistically worse (P < .0001). A significant visual improvement was observed in the majority of the study group eyes (71%); permanent visual loss occurred in 4 eyes (1.7%). CONCLUSIONS: Anterior capsule tear can lead to additional intraoperative complications, with a relatively high incidence of secondary interventions. Overall, permanent visual loss can be observed and worse refractive outcomes are to be expected, particularly if the lens is being implanted out of the bag.