Predicting Long-Term Endothelial Cell Loss after Preloaded Descemet Membrane Endothelial Keratoplasty in Fuchs' Endothelial Corneal Dystrophy: A Mathematical Model.

(1) Background: This study offers a biexponential model to estimate corneal endothelial cell decay (ECD) following preloaded "endothelium-in" Descemet membrane endothelial keratoplasty (DMEK) in Fuchs' endothelial corneal dystrophy (FECD) patients; (2) Methods: A total of 65 eyes undergoing DMEK alone or combined with cataract surgery were evaluated. The follow-up period was divided into an early phase (first 6 months) and a late phase (up to 36 months). Endothelial cell count (ECC) and endothelial cell loss (ECL) were analyzed; (3) Results: The half time of the ECD was 3.03 months for the early phase and 131.50 months for the late phase. The predicted time-lapse interval to reach 500 cells/mm2 was 218 months (18.17 years), while the time-lapse interval to reach 250 cells/mm2 was 349 months (29.08 years). There was no statistically significant difference between the ECL in DMEK combined with cataract extraction and DMEK alone at 24 months (p ≥ 0.20). At the late phase, long-term ECL prediction revealed a lower ECC half time in patients undergoing DMEK combined with cataract surgery (98.05 months) than DMEK alone (250.32 months); (4) Conclusions: Based on the mathematical modeling, a predicted average half-life of a DMEK graft could reach 18 years in FECD. Moreover, combining cataract extraction with DMEK could result in excessive ECL in the long term.

Clinical Outcomes of Preloaded Descemet Membrane Endothelial Keratoplasty With Endothelium Inward: A 24-Month Comparative Analysis Between Fuchs Endothelial Corneal Dystrophy and Bullous Keratopathy.

PURPOSE: The aim of this study was to compare long-term clinical outcomes of preloaded Descemet membrane endothelial keratoplasty (DMEK) between Fuchs endothelial corneal dystrophy (FECD) and bullous keratopathy (BK). METHODS: In this single-center retrospective clinical case series, 71 eyes of 64 patients indicated with FECD (62%) or BK (38%) (with or without cataract) were treated with preloaded DMEK grafts between March 2018 and February 2020. Standard DMEK peeling, followed by manual folding of the tissue with endothelium-inward orientation and storing in a preloaded fashion inside a 2.2-mm intraocular lens cartridge. All tissues were delivered using a bimanual pull-through technique, followed by air tamponade. Graft unfolding time, endothelial cell loss, corrected distance visual acuity, central corneal thickness, rebubbling rate, and intraoperative and postoperative complications at 1, 3, 6, 12, and 24 months were recorded. RESULTS: The mean intraoperative graft unfolding time in FECD did not differ from the BK group ( P = 0.6061). Cystoid macular edema did not differ in either group ( P = 0.6866). The rebubbling rate was found to be significantly higher in FECD compared with the BK group ( P = 0.0423). Corrected distance visual acuity significantly improved at the first month after surgery ( P = 0.0012), with no differences between FECD and BK at 24 months ( P = 0.2578). Central corneal thickness was stable postoperatively and showed no differences between the groups ( P = 0.3693). Significantly higher endothelial cell counts were observed in the FECD group at 24 months ( P = 0.0002). CONCLUSIONS: Preloaded DMEK with "endothelium-in" offers acceptable intraoperative time, rebubbling rate, and clinical outcomes in both FECD and BK groups. Patients with FECD show better postoperative clinical outcomes even if the rebubbling rate is relatively high.

Outcomes of 195 consecutive patients undergoing 2-port pars plana vitrectomy with slit-lamp illumination system for posterior segment disease: a retrospective study.

PURPOSE: The purpose of this study was to evaluate the safety and efficacy of 2-port 20-gauge pars plana vitrectomy with a slit-lamp illumination system in different vitreoretinal pathologies. DESIGN: : Retrospective, consecutive, interventional case series. METHODS: One hundred and ninety-five consecutive eyes of 195 patients underwent 20-gauge 2-port pars plana vitrectomy with a combination of slit-lamp illumination and a plano-concave contact lens, at the San Paolo Ophthalmology Center, from September 2005 through November 2007. Postoperative visual acuity at baseline and at 1, 3, and 6 months; intraoperative and postoperative complication rate; and surgical time were evaluated. RESULTS: All patients completed 6 months of follow-up. The mean overall visual acuity was 0.74 ± 0.03 (mean ± SD) at baseline, improving to 0.56 ± 0.03 (P < 0.0001), 0.48 ± 0.03 (P < 0.0001), and 0.43 ± 0.03 (P < 0.0001) at 1, 3, and 6 months, respectively. No intraoperative complications occurred. Postoperative complications included retinal detachment in three patients, epiretinal membrane recurrence in three eyes, persistent macular hole in four eyes, and phthisis in one eye. Cataract formation was observed in 25 eyes. The total mean surgical time was 28.3 ± 10.1 minutes. No one had hypotony after the surgical procedure, and no cases of endophthalmitis were observed. Conversion to standard three-port vitrectomy was not necessary in any of the cases. CONCLUSION: Two-port 20-gauge pars plana vitrectomy with slit-lamp illumination is a safe and effective procedure for posterior segment surgeries.

Single-session photodynamic therapy combined with intravitreal bevacizumab for retinal angiomatous proliferation.

PURPOSE: To evaluate the efficacy of single-session photodynamic therapy (PDT) combined with intravitreal bevacizumab (IVB) in the treatment of retinal angiomatous proliferation (RAP) in age-related macular degeneration. METHODS: In this pilot study, eight patients with RAP underwent indocyanine green angiography (ICGA)-guided single-session verteporfin PDT followed by intravitreal bevacizumab (1.25 mg) within a 0-day +/- 1-day interval. All patients were naïve to treatment. Best-corrected visual acuity (BCVA), fluorescein angiography, ICGA, and optical coherence tomography (OCT) were performed at baseline and at each follow-up visit. All patients received three consecutive monthly IVB injections; thereafter, retreatment with bevacizumab was performed in the case of worsening BCVA or a deterioration of angiographic or OCT findings. RESULTS: All patients had 9 months of follow-up. Complete resolution of angiographic leakage was achieved in all eyes at 9 months. A significant improvement in the mean BCVA was observed at 1 month, 3 months, 6 months, and 9 months after combined treatment (P = 0.004). Visual acuity improved in 62.5% and was stable in 37.5% of cases. No patients had a decrease in BCVA of three or more lines during follow-up. Mean central macular thickness was significantly reduced in all patients (P < 0.0001) as controlled at 1-month, 3-month, 6-month, and 9-month intervals from initial treatment. The mean number of injections for the 9 months were 3.2 +/- 0.4. No ocular complications or systemic events developed. CONCLUSION: Sequenced combined treatment with single-session PDT and IVB injections may be useful in treating RAP, reducing or eliminating retinal edema, and improving or stabilizing visual acuity. Further investigations are warranted to outline the appropriate treatment paradigm for combination therapy.

The deep subfascial approach to the temporomandibular joint.

PURPOSE: The aim of the present study was to improve safety and visibility in the surgical approach to the temporomandibular joint (TMJ). In spite of the development of a myriad of surgical approaches to the TMJ, the facial nerve remains at risk for damage. For this reason the authors present an additional, safe, surgical approach to avoid injuries of the facial nerve during TMJ surgery, termed "the deep subfascial approach." PATIENTS AND METHODS: Two resident surgeons, under supervision of the Department Chief, made 29 surgical exposures of the condyle, safely using the deep subfascial approach. This surgical approach is carried out by means of a modified preauricular incision followed by the subfascial dissection. Dissection passes under both layers of the deep temporalis fascia. RESULTS: Neither permanent nor temporary motor loss of the frontal branch of the facial nerve was observed after surgery. It has not been necessary to ligate the superficial temporal vessels except the posterior branch of the superficial temporal artery. Aesthetic results were excellent in all cases. CONCLUSION: The operation is technically facile, surgically uncomplicated, and clinically effective. It is our opinion that the deep subfascial approach to the TMJ represents a safe method to avoid injury of the facial nerve. We suggest this surgical procedure as a routine and safe approach to the TMJ and to the zygomatic arch, especially in second procedures or in delayed treatments.

Stability of skeletal class III malocclusion after combined maxillary and mandibular procedures: rigid internal fixation versus wire osteosynthesis of the mandible.

PURPOSE: The aim of this study was to evaluate skeletal stability after double-jaw surgery for correction of skeletal Class III malocclusion to assess whether there were any differences between wire and rigid fixation of the mandible. PATIENTS AND METHODS: Thirty-seven Class III patients had Le Fort I osteotomy stabilized with plate and screws for maxillary advancement. Bilateral sagittal split osteotomy for mandibular setback was stabilized with wire osteosynthesis and maxillomandibular fixation for 6 weeks in 20 patients (group 1) and with rigid internal fixation in 17 patients (group 2). Lateral cephalograms were taken before surgery, immediately after surgery, 8 weeks after surgery, and 1 year after surgery. RESULTS: Before surgery, both groups were balanced with respect to linear and angular measurements of craniofacial morphology. One year after surgery, maxillary sagittal stability was excellent in both groups, and bilateral sagittal split osteotomy accounted for most of the total horizontal relapse observed. In group 1, significant correlations were found between maxillary advancement and relapse at the posterior maxilla and between mandibular setback and postoperative counterclockwise rotation of the ramus and mandibular relapse. In group 2, significant correlations were found between mandibular setback and intraoperative clockwise rotation of the ramus and between mandibular setback and postoperative counterclockwise rotation of the ramus and mandibular relapse. No significant differences in postoperative skeletal and dental stability between groups were observed except for maxillary posterior vertical position. CONCLUSIONS: Surgical correction of Class III malocclusion after combined maxillary and mandibular procedures appears to be a fairly stable procedure independent of the type of fixation used to stabilize the mandible.