Cytomegalovirus anterior uveitis and occlusive retinal vasculitis without retinitis in a patient on immunomodulatory therapy.

PURPOSE: To describe unusual clinical features and therapeutic management of a case of cytomegalovirus (CMV) ocular disease in a patient on immunomodulatory therapy. SETTING/VENUE: Moorfields Eye Hospital NHS Foundation Trust, London, UK. METHODS: Medical history, clinical findings, investigation results, and multimodal imaging were retrospectively collected. RESULTS: A 61-year-old, South-East Asian man, developed CMV-related endotheliitis and occlusive retinal vasculitis, diagnosed by wide-angle fluorescein angiography. No retinitis was present on the fundus examination. Suspicion of CMV etiology was based on anterior segment findings, especially the presence of coin-shaped endothelial lesions. The diagnosis was confirmed by aqueous polymerase chain reaction (PCR) analysis which was positive for CMV DNA. The combined use of topical and systemic valganciclovir resulted in significant improvement of the picture. CONCLUSIONS: CMV can manifest in the eye as occlusive retinal vasculitis without the presence of typical retinitis.

Comparison of repeat penetrating keratoplasty, DSAEK and DMEK for the management of endothelial failure of previous PK.

PURPOSE: To compare the clinical outcomes of repeat PK, DSAEK-on-PK or DMEK-on-PK for the management of endothelial failure of previous penetrating keratoplasty. DESIGN: Retrospective, interventional consecutive case series. PARTICIPANTS: 104 consecutive eyes of 100 patients requiring a second keratoplasty for endothelial failure of their primary penetrating keratoplasty performed between September 2016 and December 2020. INTERVENTION: Repeat keratoplasty. MAIN OUTCOME MEASURES: Survival and visual acuity at 12 and 24 months, rebubbling rate and complications. RESULTS: Repeat PK was performed in 61/104 eyes (58.7%), DSAEK-on-PK was performed in 21/104 eyes (20.2%) and DMEK-on-PK was performed in 22/104 eyes (21.2%). Failure rates in the first 12 and 24 months were 6.6% and 20.6% for repeat PKs compared to 19% and 30.6% for DSAEK and 36.4% and 41.3% for DMEK. For those grafts surviving 12 months, the chances of surviving to 24 months were greatest for DMEK-on-PK at 92% vs 85% each for redo PK and DSAEK-on-PK. Visual acuity at one year was logMAR 0.53 ± 0.51 in the redo PK group, 0.25 ± 0.17 for DSAEK-on-PK and 0.30 ± 0.38 for DMEK-on-PK. 24-month outcomes were 0.34 ± 0.28, 0.08 ± 0.16, and 0.36 ± 0.36 respectively. CONCLUSIONS: DMEK-on-PK has a greater failure rate in the first 12 months than DSAEK-on-PK which has a greater failure rate than redo PK. However, the 2-year survival rates in our series for those already surviving 12 months were greatest for DMEK-on-PK. There was no significant difference in visual acuity at 12 or 24 months. Careful patient selection is needed by experienced surgeons to determine which procedure to offer to patients.

Clinical Outcomes of Descemet Membrane Endothelial Keratoplasty in Pseudophakic Eyes Compared With Triple-DMEK at 1-Year Follow-up.

PURPOSE: To compare the survival rate 1 year after Descemet membrane endothelial keratoplasty (DMEK) in pseudophakic eyes versus combined phacoemulsification and DMEK (triple-DMEK). METHODS: Retrospective, interventional, consecutive case series. From all DMEKs performed from January 1, 2017, to June 30, 2018, we selected those performed in pseudophakic eyes (pseudophakic DMEK) and those that underwent triple-DMEK. We compared the survival rate 1 year after surgery between both groups and between the Fuchs endothelial dystrophy (FED) cases in both groups, plus the FED cases versus the pseudophakic bullous keratopathy (PBK) cases in the pseudophakic DMEK group. Second, we compared rebubbling rates and the influence of the use of gas or corneal sutures on rebubbling and dislocation rates. RESULTS: A total of 329 eyes were included (218 eyes pseudophakic DMEK and 111 eyes triple-DMEK). The survival rate at 1 year was 79.8% and 90%, respectively (P = 0.03). When only FED cases were included (133 pseudophakic DMEK and 108 triple-DMEK), no significant difference was found (87.9% vs. 90.7%, P = 0.59). Within the pseudophakic DMEK group, the survival rate was higher in FED cases (87.8%) compared with PBK cases (66.6%) (P = 0.0001). Rebubbling rates were 21.1% (pseudophakic DMEK) and 17.1% (triple-DMEK) (P = 0.39). The use of gas versus air or placing corneal sutures did not seem to influence the rebubbling (P = 0.64 and P = 0.13, respectively) or dislocation rates (P = 0.71 and P = 0.53, respectively). CONCLUSIONS: In the FED cases, performing phacoemulsification before DMEK or doing a combined procedure did not seem to affect the rebubbling or survival rate up to 1 year postoperatively. PBK was associated with a higher failure rate compared with that of FED.

Long-Term Review of Penetrating Keratoplasty: A 20-Year Review in Asian Eyes.

PURPOSE: To review the long-term outcomes of optical, therapeutic and tectonic forms of penetrating keratoplasty over a 20-year period in Asian eyes. DESIGN: Prospective cohort study involving the Singapore Corneal Transplant Study (SCTS). METHODS: All penetrating keratoplasties (PK) performed at the Singapore National Eye Centre (SNEC) from January 1991 to December 2010 were analyzed using records from the computerized database of the SCTS. This database includes preoperative, intraoperative, and postoperative patient data and donor cornea data. Only primary grafts were included. Patient demographics, donor cornea source, indications for grafting, complications, graft survival rate, and causes of graft failure were analyzed. RESULTS: A total of 1,206 primary PKs were performed. The mean age of the patients was 55 years (range: <1-101 years). The overall corneal graft survival rates at 1, 5, 10, 15, and 20 years were 91%, 66.8%, 55.4%, 52%, and 44%, respectively. For optical grafts, pseudophakic bullous keratopathy, postinfectious corneal scarring and thinning and keratoconus were the most common diagnoses. Graft survival for optical grafts was significantly better than therapeutic and tectonic grafts at all time points. Multivariate analysis suggested that a younger donor cornea age and higher donor endothelial cell count are associated with better long-term graft survival for optical grafts. Irreversible allograft rejection and late endothelial failure accounted for more than 60% of graft failures. CONCLUSIONS: Graft survival decreased over time from 91% at 1 year to 44% at 20 years' follow-up. Allograft rejection and late endothelial failure accounted for more than 60% of graft failures.

Understanding the Dual Dilemma of Dry Eye and Glaucoma: An International Review.

Glaucoma-related ocular surface disease (G-OSD) is a significant, yet often underdiagnosed, ocular co-morbidity affecting 40% to 59% of glaucoma patients worldwide. Although the use of topical glaucoma medications represents a proven strategy to control the untoward effects of high intraocular pressure, this treatment can profoundly disrupt the homeostasis of the tear film. The cumulative effect of medications, preservatives, and excipients alter underlying cellular structures which results in tear film abnormalities and instability of the ocular surface. Furthermore, these chronic inflammatory changes have been shown to impact efficacy of glaucoma treatment, patient compliance with therapy and overall quality of life. The pathogenesis of G-OSD is multifactorial and involves a vicious self-perpetuating cycle of inflammatory cytokines and proteins. The diagnosis of such disease is based on similar tests used in assessing traditional dry eye, taking into consideration findings specific to this patient population. The hallmark of treatment for these patients is to minimize the ocular surface inflammatory response by choosing glaucoma therapies that spare the ocular surface such as preservative free formulations and initiating dry eye treatment early in the course of care. In summary, glaucoma affects millions of patients around the world and chronic use of topical glaucoma medications may negatively impact the patient's ocular surface, symptoms, and vision. Understanding the pathogenesis of G-OSD, recognizing its risk factors and incorporating diagnostic and therapeutic strategies that restore and maintain ocular surface homeostasis will result in improved care for our patients.

Idiopathic stromal keratitis resembling central toxic keratopathy.

UNLABELLED: A 28-year-old previously emmetropic woman presented with a 2-day history of bilateral photophobia and blurred vision. She had no history of corneal surgery or contact lens use. Snellen uncorrected distance visual acuity (UDVA) was 6/12 bilaterally. Bilateral anterior stromal infiltration of the central cornea was seen, with no overlying epithelial defect and intact sensation. There was a marked hyperopic shift, central corneal thinning, and associated keratometric flattening. The patient was started on topical corticosteroids. Over 12 weeks, the UDVA returned to 6/5 with emmetropization of the refractive status and thickening of the central cornea. The clinical findings in our patient resemble those of central toxic keratopathy (CTK) in post-refractive-surgery cases, suggesting a similar mechanism. To our knowledge, this is the first report of a patient presenting with a CTK-like syndrome in the absence of previous keratorefractive surgery or contact lens use. The pathophysiology of this condition remains elusive and requires further investigation. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Intraoperative anterior segment optical coherence tomography: a novel assessment tool during deep anterior lamellar keratoplasty.

PURPOSE: To describe the use of high-resolution anterior segment optical coherence tomography (AS-OCT) during deep anterior lamellar keratoplasty (DALK). DESIGN: Prospective case series. METHODS: At the Singapore National Eye Centre we performed sequential intraoperative AS-OCT scans using iVue 100-2 (Optovue, Fremont, CA, USA) during various DALK techniques. RESULTS: In case 1 (corneal scarring) the OCT images helped to guide manual dissection, showed the depth of the needle track before air injection, and identified the location of a small bubble when the big bubble failed. In cases 2 (macular dystrophy) and 3 (lattice), viscodissection was undertaken, but in case 2 the OCT showed the viscoelastic trapped intrastromally, compared to case 3, in which the viscobubble dissection was successful. In case 4 (irregular corneal thinning and scarring), AS-OCT enabled accurate decision on initial trephination and guided dissection. In case 5 (keratoconus), the OCT showed the achieved big-bubble and detached Descemet membrane. Case 6 was a repeat DALK; the OCT guided the manual dissection of the residual stroma underlying the failed graft. In case 7, the OCT showed an intrastromal retention of fluid that was not detectable by the operating microscope due to diffuse scarring following alkaline injury. The OCT helped to assess the location of the Descemet membrane and guided the manual dissection. CONCLUSIONS: Intraoperative high-definition AS-OCT obtained good-quality images of the cornea during DALK and proved useful in various cases of DALK to help the surgeon decide on a number of surgical steps.

Comparison of keratocyte density after femtosecond laser vs mechanical microkeratome from 3 months up to 5 years after LASIK.

BACKGROUND: To compare keratocyte density after mechanical microkeratome LASIK (MK-LASIK) and femtosecond-laser assisted LASIK (FS-LASIK). METHODS: We performed a prospective study of myopic patients that underwent MK-LASIK or FS-LASIK. We measured keratocyte density 3 and 15 months, and 3-5 years after the surgery using confocal microscopy, and compared them with healthy, non-operated corneas. RESULTS: Thirty-one eyes were included in the FS-LASIK group, 30 in the MK-LASIK group and 28 in the control group. Three months postoperatively, there was an increase in the keratocyte population of the whole cornea, mainly due to the mid and posterior stromal layers, in both treatment groups. It was also increased in the stromal bed after MK-LASIK, but not after FS-LASIK. In both groups, this was followed by a normalisation and stabilisation of cell density in those deeper layers 15 months after the surgery. Keratocyte density in the flap and stromal bed was decreased 15 months after FS- and MK-LASIK compared to 3 months postoperatively and compared to controls. It seemed to remain stable thereafter. In spite of this decrease, the average cell density throughout the cornea was not decreased compared to controls at any time point. CONCLUSION: We found a reorganization of keratocytes density after LASIK, with an initial increase, followed by a decrease in the stromal flap and stromal bed 15 months postoperatively, and stable from then onwards, but still maintaining normal average densities in the total cornea. There were no differences between MK- and FS-LASIK.

Keratocyte density 3 months, 15 months, and 3 years after corneal surface ablation with mitomycin C.

PURPOSE: To study the effects of surface ablation with mitomycin C (MMC) on keratocyte population. DESIGN: Prospective, nonrandomized, interventional, comparative case series. METHODS: Thirty two eyes treated with surface ablation with 0.02% MMC were compared with nontreated eyes at Vissum Santa Hortensia, Madrid, Spain. Keratocyte density was measured with the Heidelberg Retina Tomograph II (Rostock Cornea Module) 3, 15, and 36 to 42 months after the surgery in the anterior, mid, and posterior stroma, and compared with control eyes. RESULTS: Three months postoperatively, we found a lower stromal bed density compared to controls (16 993 ± 8001 vs 29 660 ± 5904 cells/mm(3), P = .0001), while there was a significantly higher cell density in the mid (30 783 ± 9300 vs 18 505 ± 1996 cells/mm(3), P = .0001) and deep stroma (30 268 ± 8321 vs 18 438 ± 2139 cells/mm(3), P = .0001). Three years after the surgery, the cellularity in the stromal bed had not significantly changed from the 3-month follow-up, but the density in the mid (18 889 ± 3474 cells/mm(3)) and posterior stroma (18 992 ± 3402 cells/mm(3)) had decreased to show no difference from controls. The mean cell density between the anterior, mid, and posterior stroma was not significantly different from controls 15 months and 3 years after the surgery. CONCLUSION: Our study suggests that there is a reorganization of the stromal cell population soon after surface ablation with MMC, with a decrease in the stromal bed compensated initially with an increase in the mid and posterior stroma. Corneal cellularity tends to normalize over time, and 3 years postoperatively the mean cell density throughout the cornea seems to maintain normal values.

Femtosecond laser vs mechanical microkeratome for hyperopic laser in situ keratomileusis.

PURPOSE: To compare the outcomes of laser in situ keratomileusis (LASIK) performed with a femtosecond laser vs a mechanical microkeratome for the correction of low to moderate hyperopia. DESIGN: Retrospective, nonrandomized, interventional, comparative case series. METHODS: settings: Vissum Santa Hortensia, Madrid, Spain.study population and procedures: Patients who had undergone LASIK to correct their hyperopia using the 60-kHz IntraLase femtosecond laser were compared to age- and refraction-matched patients in whom the Moria M2 microkeratome was used. Visual and refractive results 3 months postoperatively were compared between both groups. RESULTS: A total of 144 eyes were analyzed (72 in each group). Mean preoperative sphere was +3.45 ± 1.0 diopters (D) in the IntraLase group vs +3.18 ± 1.3 D in the M2 group (P = .1). Results 3 months postoperatively were: mean residual sphere, +0.44 ± 0.6D vs +0.72 ± 0.8 D (P = .02), respectively; uncorrected visual acuity (UCVA), 0.89 ± 0.2 vs 0.80 ± 0.2 (P = .04); best spectacle-corrected visual acuity (BSCVA), 0.96 ± 0.2 vs 0.92 ± 0.2 (P = .2); safety index, 0.97 ± 0.1 vs 0.98 ± 0.1 (P = .5); efficacy index, 0.89 ± 0.2 vs 0.84 ± 0.2 (P = .3). CONCLUSIONS: Hyperopic LASIK performed with the IntraLase femtosecond laser seems to achieve better refractive results 3 months after the surgery compared to the M2 microkeratome, without significant differences in safety between both procedures.

Keratocyte density after laser-assisted subepithelial keratectomy with mitomycin C.

PURPOSE: To study the effects of laser-assisted subepithelial keratectomy (LASEK) with mitomycin C (MMC) on the keratocyte population. DESIGN: Prospective, nonrandomized, interventional, comparative case series. METHODS: Fifty-six eyes treated at Vissum Santa Hortensia, Madrid, Spain, were included in the study. We compared 28 eyes treated with LASEK with intraoperative 0.02% MMC versus 28 non-treated eyes. Keratocyte density was measured 3 months after the surgery in the anterior, mid, and posterior stroma and was compared with the corresponding layers in the control eyes. The anterior layer in the LASEK group was compared with 2 layers in the control group: the most anterior stromal layer and the 80 µm-deep layer, because that was the mean ablation depth performed in eyes that underwent LASEK. RESULTS: We found a statistically significantly lower keratocyte population in the most anterior stromal layer after LASEK with MMC compared with both the most anterior stromal layer and the 80 µm-deep layer in controls. On the contrary, the treated group showed a significantly higher keratocyte density in both the mid stroma and the deep stroma. The comparison between the average densities through the entire cornea showed a significantly higher keratocyte population in the LASEK with MMC group. CONCLUSIONS: LASEK with MMC seems to cause a decrease in the anterior stromal cells 3 months after the surgery compared with nonoperated corneas. There seems to be a compensating proliferation of keratocytes in the deeper corneal layers, suggesting that the ability of keratocytes to repopulate the cornea is maintained after the surgical procedure.

Efficacy of surface ablation retreatments using mitomycin C.

PURPOSE: To evaluate the visual and refractive results and the incidence of complications after laser subepithelial keratectomy (LASEK) enhancement using mitomycin C (MMC) after a previous LASEK procedure with MMC. DESIGN: Retrospective, noncomparative, interventional case series. METHODS: Setting was Vissum Santa Hortensia, Madrid, Spain. We performed a retrospective study of LASEK-treated eyes that received intraoperative MMC for 30 seconds and that needed an enhancement procedure. LASEK retreatment with MMC 0.02%, applied for 60 seconds, was performed 3 to 6 months after the initial surgery. We measured the visual and refractive results 3 months after the enhancement and the incidence of complications. RESULTS: Eighty-two eyes were included in the study. The preoperative data were best spectacle-corrected visual acuity (BSCVA) 1.08 +/- 0.19, sphere -4.68 +/- 2.8 diopters (D), and cylinder -1.30 +/- 1.20 D. Three to 6 months postoperatively, before enhancement, the uncorrected VA (UCVA) was 0.59 +/- 0.2; the BSCVA, 0.976 +/- 0.2; the residual sphere, +0.17 +/- 0.7 D, and the cylinder, -0.39 +/- 0.5 D. Three months after retreatment, the UCVA was 0.93 +/- 0.1; the BSCVA, 0.977 +/- 0.1; the residual sphere, 0.09 +/- 0.3 D; and the residual cylinder, -0.2 +/- 0.3 D. The safety index after retreatment was 1.01 +/- 0.1, and the efficacy index was 0.96 +/- 0.1. No haze, no delay in epithelial healing, and no case of endothelial decompensation were detected. CONCLUSION: Surface ablation retreatment using MMC seems to be effective to correct residual refractive errors after an initial surgery with MMC.

Comparison of real-time intraocular pressure during laser in situ keratomileusis and epithelial laser in situ keratomileusis in porcine eyes.

PURPOSE: To compare real-time intraocular pressure (IOP) between laser in situ keratomileusis (LASIK) and epithelial LASIK (epi-LASIK) in porcine eyes during flap creation using a microkeratome or an epikeratome, respectively. SETTING: Vissum Madrid, Madrid, Spain. METHODS: In this prospective study, a Moria microkeratome was used in 1 eye (LASIK group) and an Epi-K epikeratome in the other eye (epi-LASIK group) to create a lamellar corneal flap and an epithelial flap, respectively, in freshly enucleated porcine eyes. The IOP changes during the procedures were recorded by direct cannulation using a reusable blood pressure transducer connected to the anterior chamber. RESULTS: Each group comprised 17 eyes. In the LASIK group, the mean IOP was 113.65 mm Hg +/- 10.78 (SD) during suctioning and 112.35 +/- 11.51 mm Hg during cutting phases. The mean duration of the phases was 9.00 +/- 1.46 seconds and 6.06 +/- 1.14 seconds, respectively. In the epi-LASIK group, the mean IOP was 92.57 +/- 20.86 mm Hg during suctioning, 82.09 +/- 20 mm Hg during cutting, and 67.28 +/- 13.49 during low vacuum. The mean duration of the phases was 25.88 +/- 1.96 seconds, 33.82 +/- 2.81 seconds, and 29.71 +/- 3.29 seconds, respectively. The IOP values were significantly different between the 2 groups (all comparisons P<.05). CONCLUSION: Real-time IOP measured during suctioning and flap creation by direct cannulation of the anterior chamber in freshly enucleated porcine eyes showed a significant increase in IOP during LASIK and epi-LASIK; the increase was lower in the epi-LASIK group.