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PURPOSE: To compare long-term outcomes of simultaneous accelerated corneal crosslinking (CXL) with intrastromal corneal ring segments (CXL-ICRS) with simultaneous accelerated CXL with topography-guided photorefractive keratectomy (CXL-TG-PRK) in progressive keratoconus (KC). SETTING: Kensington Eye Institute and Bochner Eye Institute, Toronto, Canada. DESIGN: Prospective nonrandomized interventional study. METHODS: The change in visual and topographical outcomes of CXL-ICRS and CXL-TG-PRK 4 to 5 years postoperatively were compared using linear regression models adjusted for preoperative corrected distance visual acuity (CDVA) and maximum keratometry (Kmax). RESULTS: 57 eyes of 43 patients with progressive KC who underwent simultaneous accelerated (9 mW/cm 2 , 10 minutes) CXL-ICRS (n = 32) and CXL-TG-PRK (n = 25) were included. Mean follow-up duration was 51.28 (9.58) and 54.57 (5.81) months for the CXL-ICRS and CXL-TG-PRK groups, respectively. Initial mean Kmax was higher in the CXL-ICRS group compared with the CXL-TG-PRK group (60.68 ± 6.81 diopters [D] vs 57.15 ± 4.19 D, P = .02). At the last follow-up, change (improvement) in logMAR uncorrected distance visual acuity (UDVA) compared with that preoperatively was significant with CXL-ICRS (-0.31 ± 0.27, P < .001, which is equivalent to approximately 3 lines) and not significant with CXL-TG-PRK (-0.06 ± 0.42, P = .43). The logMAR CDVA improved significantly with CXL-ICRS (-0.22 ± 0.20, P < .001), but not with CXL-TG-PRK (-0.05 ± 0.22, P = .25). Adjusting for baseline Kmax and CDVA, the improvement in UDVA was significantly greater with CXL-ICRS than with CXL-TG-PRK (-0.27, 95% CI, 0.06-0.47, P = .01). Improvement in CDVA was not significantly different. CONCLUSIONS: In this cohort of progressive KC with long-term follow-up, UDVA showed more improvement with accelerated CXL-ICRS than with CXL-TG-PRK.
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Queratocono , Refracción Ocular , Humanos , Fármacos Fotosensibilizantes/uso terapéutico , Riboflavina/uso terapéutico , Estudios Prospectivos , Terapia Combinada , Sustancia Propia/cirugía , Topografía de la Córnea , Queratocono/tratamiento farmacológico , Queratocono/cirugía , Reactivos de Enlaces Cruzados/uso terapéuticoRESUMEN
PURPOSE: The aim of the study was to report clinical outcomes of Descemet membrane endothelial keratoplasty (DMEK) combined with transscleral-sutured intraocular lens (IOL) compared with DMEK combined with phacoemulsification and posterior chamber IOL (Phaco-DMEK). METHODS: A retrospective chart review of all patients who underwent DMEK combined with transscleral-sutured intraocular lens fixation or combined with phacoemulsification for Fuchs endothelial corneal dystrophy from 2016 to 2021 at the Toronto Western Hospital or the Kensington Eye Institute (Toronto, ON, Canada) and had at least 18 months of follow-up was performed. Main outcomes were postoperative distance-corrected visual acuity, rebubbling rate, graft survival rate, and complications. RESULTS: Twenty-one cases of DMEK combined with transscleral-sutured IOL (DMEK-TSS-IOL) and 44 cases of Phaco-DMEK were evaluated. Twelve eyes (57.15%) had a foldable acrylic 3-piece IOL (AR40E) and 9 (42.85%) had a single-piece polymethylmethacrylate (PMMA) IOL (CZ70BD). LogMAR distance-corrected visual acuity improved significantly from 1.48 ± 0.62 (SD) to 0.86 ± 0.82 ( P = 0.01) 12 months after DMEK-TSS-IOL and from 0.41 ± 0.29 logMAR to 0.11 ± 0.11 logMAR ( P < 0.0001) after Phaco-DMEK. No statistically significant differences were observed in donor ( P = 0.97) or 1-year postoperative endothelial cell density ( P = 0.11) between the groups. Rebubbling was necessary in 33.33% of eyes in DMEK-TSS-IOL compared with 25% of Phaco-DMEK eyes ( P = 0.55). Graft survival rate was 76.19% in the DMEK-TSS-IOL group compared with 90.90% in the Phaco-DMEK group ( P = 0.13). CONCLUSIONS: Transscleral-sutured IOL combined with DMEK is an option for the management of endothelial diseases in aphakic eyes or those which require IOL exchange for the experienced surgeon. However, when compared with routine Phaco-DMEK, there are higher complication and lower survival rates at 18 months.
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Queratoplastia Endotelial de la Lámina Limitante Posterior , Distrofia Endotelial de Fuchs , Lentes Intraoculares , Humanos , Lámina Limitante Posterior/cirugía , Endotelio Corneal/trasplante , Estudios Retrospectivos , Distrofia Endotelial de Fuchs/cirugíaRESUMEN
OBJECTIVES: To compare outcomes of femtosecond-enabled deep anterior lamellar keratoplasty (FE-DALK) and standard deep anterior lamellar keratoplasty (S-DALK). METHODS: An open label, randomized controlled trial (Kensington Eye Institute, Toronto, ON, Canada) including 100 eyes of 97 participants with either keratoconus or corneal scarring, randomized to either FE-DALK (n = 48) or S-DALK (n = 49). PRIMARY OUTCOMES: postoperative astigmatism and surgically induced corneal astigmatism (SIA) - both at 15 months. SECONDARY OUTCOMES: 6-, 12- and 15-month postoperative uncorrected- and best spectacle-corrected visual acuity, steep and flat keratometry, manifest sphere and astigmatism, rate of conversion to penetrating keratoplasty (PK), big-bubble success, central corneal thickness, endothelial cell count and complications. RESULTS: In intention-to-treat analysis, mean postoperative astigmatism in the FE-DALK (n = 30) and S-DALK (n = 30) groups at 15 months was 7.8 ± 4.4 D and 6.3 ± 5.0 D, respectively (p = 0.282) with an adjusted mean difference of 1.3 D (95% CI -1.08, +3.65). Mean SIA (arithmetic) was 9.2 ± 7.8 and 8.8 ± 5.4 D, respectively (p = 0.838) with a mean difference of 0.4 D (95% CI -3.13, +3.85). In an analysis of successful DALK cases only, mean postoperative astigmatism in the FE-DALK (n = 24) and S-DALK (n = 20) groups at 15 months (after excluding 4 eyes with AEs) was 7.3 ± 4.4 and 6.2 ± 4.9 D, respectively (p = 0.531) with an adjusted mean difference of 0.9 D (95% CI -1.94, +3.71). Mean SIA (arithmetic) was 9.1 ± 7.8 and 7.9 ± 4.6 D, respectively (p = 0.547) with a mean difference of 1.2 D (95% CI -2.70,+5.02). Comparison of secondary outcomes showed only weak statistical evidence. CONCLUSIONS: In this randomized controlled trial, FE-DALK and S-DALK showed comparable functional and anatomical outcomes.
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Astigmatismo , Trasplante de Córnea , Queratocono , Humanos , Agudeza Visual , Astigmatismo/cirugía , Resultado del Tratamiento , Queratoplastia Penetrante , Queratocono/cirugía , Estudios Retrospectivos , Estudios de SeguimientoRESUMEN
OBJECTIVE: To compare subjective and objective outcomes of 4 different Descemet membrane endothelial keratoplasty (DMEK) peeling techniques performed by novice surgeons at different stages in their surgical career. DESIGN: An ex vivo prospective study. METHODS: In the first round, 2 DMEK peeling techniques were pitched against each other: the peripheral scoring and Sinskey dissection technique with the peripheral scoring and microhoe dissection and the peripheral blunt microhoe dissection against the scleral spurectomy and microhoe dissection. Three surgeons with different operative experience performed the peeling. Outcome measures included graft peeling time, surgeon's peeling difficulty grading (on a scale of 1-10, 1 being the easiest and 10 the hardest), number of radial and circumferential tears before and after trephination, and tissue loss. The 2 techniques that performed the best from the first round proceeded to the final round to identify the best overall technique. RESULTS: In total, 90 tissues (45 pairs) were peeled by 3 surgeons. Following the first-round results, the peripheral scoring and Sinskey dissection and peripheral blunt microhoe dissection proceeded to the final round. There were no significant differences between the groups in terms of peeling times, subjective feeling of difficulty, post-trephination tears, and peeling success rates (P > 0.05 for all). However, the peripheral scoring and Sinskey dissection technique had significantly fewer pretrephination radial tears (1.3 ± 1.3 vs 6.1 ± 5.2, Pâ¯=â¯0.007) and circumferential tears (0.6 ± 0.9 vs 1.8 ± 2.1, Pâ¯=â¯0.02). CONCLUSIONS: This study demonstrates that the learning curve can be overcome quickly with appropriate DMEK peeling techniques. The peripheral scoring and Sinskey dissection peeling technique allows efficient peeling with fewer related tears.
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Lámina Limitante Posterior , Queratoplastia Endotelial de la Lámina Limitante Posterior , Humanos , Queratoplastia Endotelial de la Lámina Limitante Posterior/métodos , Estudios Prospectivos , Bancos de Ojos/métodos , Recolección de Tejidos y Órganos , Endotelio Corneal , Estudios RetrospectivosRESUMEN
PURPOSE: The purpose of this study was to evaluate 5-year safety and efficacy outcomes of femtosecond-enabled Descemet membrane endothelial keratoplasty (F-DMEK) in patients with Fuchs' endothelial dystrophy (FED). METHODS: This was a retrospective study, including patients with FED and cataract who underwent either F-DMEK (16 eyes of 15 patients) or manual DMEK (M-DMEK) (42 eyes of 37 patients) combined with cataract extraction. Outcome measures included visual acuity, graft detachment, graft survival, and endothelial cell loss. RESULTS: The average follow-up in F-DMEK and M-DMEK was 57.1 ± 12.4 months and 58.5 ± 17.3 months, respectively ( P = 0.757). The rates of primary failure (0% vs. 9.5%, P = 0.567), secondary failure (0% for both), and graft rejection (0% vs. 7.1%, P = 0.533) did not differ significantly between the groups. Improvement in best spectacle-corrected visual acuity was similar in F-DMEK and M-DMEK (0.32 ± 0.27 logarithm of the minimum angle of resolution and 0.35 ± 0.44 logarithm of the minimum angle of resolution, respectively, P = 0.165) and persisted at 2, 3, 4, and 5 years and at the last follow-up. The rates of graft detachment and rebubbling were significantly lower with 6.25% in F-DMEK and 33.3% in M-DMEK ( P = 0.035). Cell-loss rates were lower in F-DMEK compared with M-DMEK throughout the follow-up, significantly so up to 2 years with a difference of 8.6% at 1 year ( P = 0.023), 11.8% at 2 years ( P = 0.021), 7.6% at 3 years ( P = 0.088), 5.8% at 4 years ( P = 0.256), 13.6% at 5 years ( P = 0.169), and 7.1% at the final follow-up ( P = 0.341). CONCLUSIONS: F-DMEK had an excellent safety and efficacy profile which was maintained over 5 years of follow-up. Lower endothelial cell-loss rates in F-DMEK compared with M-DMEK may help extend the duration of graft survival.
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Queratoplastia Endotelial de la Lámina Limitante Posterior , Distrofia Endotelial de Fuchs , Humanos , Lámina Limitante Posterior/cirugía , Endotelio Corneal/trasplante , Estudios Retrospectivos , Distrofia Endotelial de Fuchs/cirugía , Rayos Láser , Recuento de CélulasRESUMEN
PURPOSE: The purpose of this study was to assess long-term stability and outcomes of femtosecond astigmatic keratotomy (FSAK) after treatment of high postkeratoplasty astigmatism. METHODS: This retrospective study included patients who underwent FSAK for high astigmatism (≥4 D) after penetrating keratoplasty or deep anterior lamellar keratoplasty. Main outcome measures were corneal astigmatism, uncorrected visual acuity, and best-corrected visual acuity (BCVA) at 1 month and 1, 5, and 10 years. RESULTS: Overall, 61 eyes of 61 patients (mean age 56 ± 19 years, 54.1% male) were included in this study. Preoperative corneal astigmatism ranged from 4 to 25 D. One month after FSAK, mean corneal astigmatism was significantly reduced from 9.02 ± 3.97 D to 4.86 ± 3.10 D ( P < 0.001). Thereafter, corneal astigmatism remained stable at all visits up to 10 years ( P < 0.05 for all compared with baseline). After FSAK, there was a significant improvement in logMAR uncorrected visual acuity from 1.21 ± 0.48 to 0.87 ±0.54 ( P < 0.001) and logMAR BCVA from 1.03 ± 0.55 to 0.49 ± 0.45 ( P < 0.001) which remained stable up to 10 years. A mild reduction in BCVA improvement was seen between 1 month and 1 year. CONCLUSIONS: Femtosecond astigmatic keratotomy was effective and stable at reducing very high magnitudes of postkeratoplasty astigmatism over the long term. The procedure also had a stable effect on visual acuity, albeit some reduction in the degree of BCVA improvement was seen over the early postoperative period.
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Astigmatismo , Enfermedades de la Córnea , Humanos , Masculino , Adulto , Persona de Mediana Edad , Anciano , Femenino , Queratoplastia Penetrante/efectos adversos , Refracción Ocular , Astigmatismo/etiología , Astigmatismo/cirugía , Estudios Retrospectivos , Topografía de la Córnea , Córnea/cirugía , Enfermedades de la Córnea/cirugía , Complicaciones Posoperatorias/cirugíaRESUMEN
OBJECTIVE: To compare outcomes of phototherapeutic keratectomy (PTK) versus epithelial debridement combined with anterior stromal puncture (ASP) or diamond burr for the treatment of recurrent corneal erosions (RCES) in a large tertiary centre. METHODS: Patients with a diagnosis of RCES secondary to trauma or epithelial basement membrane dystrophy who underwent a surgical procedure between 2009 and 2019 were included in the study. The following data were collected: demographics, ocular history, prior medical treatment, ocular surgeries, intervention, complete epithelialization at postoperative week 1, recurrences, and complications. Recurrence was defined as either an objective finding of a corneal epithelial defect or symptoms suggestive of recurrent epithelial erosion on history. Recurrence rate and time to epithelialization were compared between groups. RESULTS: A total of 97 eyes (73 patients) were included in the study. Mean patient age was 51 ± 16.1 years, and mean follow-up was 474 days. RCES was secondary to epithelial basement membrane dystrophy in 80% (nâ¯=â¯78 of 97), trauma (15%, nâ¯=â¯15 of 97), or idiopathic (4%, nâ¯=â¯4 of 97). Epithelial debridement with ASP was performed in 34 eyes (35%), diamond burr in 33 eyes (33%), and PTK in 30 eyes (31%). Compared with epithelial debridement with ASP (recurrence 29.4%), the recurrence rate was significantly lower for both the diamond burr (9.1%, pâ¯=â¯0.031) and PTK groups (10%, pâ¯=â¯0.048). The diamond burr and PTK groups also had a significantly higher rate of complete epithelialization at 1 week (p < 0.05). CONCLUSION: Compared with epithelial debridement with ASP, diamond burr and PTK have significantly lower rates of recurrence and time to epithelialization and may be considered first for surgical management of RCES.
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Enfermedades de la Córnea , Distrofias Hereditarias de la Córnea , Úlcera de la Córnea , Epitelio Corneal , Queratectomía Fotorrefractiva , Humanos , Adulto , Persona de Mediana Edad , Anciano , Desbridamiento/efectos adversos , Desbridamiento/métodos , Láseres de Excímeros/uso terapéutico , Recurrencia Local de Neoplasia/complicaciones , Recurrencia Local de Neoplasia/cirugía , Queratectomía Fotorrefractiva/métodos , Distrofias Hereditarias de la Córnea/diagnóstico , Distrofias Hereditarias de la Córnea/cirugía , Epitelio Corneal/cirugía , Punciones/efectos adversos , Recurrencia , Enfermedades de la Córnea/cirugíaRESUMEN
OBJECTIVE: To retrospectively analyze the visual outcomes of KAMRA (AcuFocus Inc, Irvine, Calif.) inlay insertion in a cohort of patients reporting success of procedure, complications, patient satisfaction, and refractive outcomes. DESIGN: Retrospective trial at the TLC Laser Centre, Toronto. METHODS: A total of 5 surgeons at the practice inserted 35 KAMRA inlays in 35 patients between October 2012 and June 2014. Some patients had a sole KAMRA inlay insertion, whereas others had combined laser vision correction (LVC) and KAMRA inlay on either the same day or sequentially. There was a small cohort of patients who had previous unrelated LVC. Mean time of follow-up was 299 days. RESULTS: After KAMRA inlay insertion there was a significant improvement in uncorrected near visual acuity (pâ¯=â¯0.00009), uncorrected intermediate visual acuity (pâ¯=â¯0.00006), and uncorrected distance visual acuity (pâ¯=â¯0.02), but levels of patient dissatisfaction were 43%. The most common cause for dissatisfaction was requirements for readers (23%), followed by dysphotopsias (11%). The explantation rate was 11.42%, and 28.5% of patients required enhancements after inlay insertion. CONCLUSIONS: The KAMRA corneal inlay has significant improvements in uncorrected near visual acuity, uncorrected intermediate visual acuity, and uncorrected distance visual acuity when used in isolation or combined with LVC. Appropriate patient selection is crucial. This procedure should not be used as first-line presbyopia management because of low levels of patient satisfaction, biocompatibility concerns, and explantation rates.
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PURPOSE: The scrolling properties of the Descemet membrane endothelial keratoplasty (DMEK) graft are essential for surgical success. Currently, there is limited knowledge on what dictates the tightness of the DMEK scroll. The purpose of this study was to determine the impact of temperature and protein digestion on DMEK graft scroll tightness. METHODS: For the temperature experiment, a total of 28 eyes were used for this study. Scrolls in the cold group were kept at 4°C while scrolls in the hot group were kept at 37°C. Scroll width was recorded at the 5-, 15-, and 30-minute mark. For the protein digestion experiment, a total of 18 eyes were exposed to collagenase A (10 CDU/mL) in Optisol solution. Scroll width was recorded at the time points of 1, 3, 5, 10, and 20 minutes. RESULTS: The results of the temperature experiment did not yield any statistically significant changes in the mean scroll width of the DMEK scrolls across both temperature ranges and observation times. For the protein digestion experiment, the mean scroll width grew from 1.85 mm to 2.13 mm from the beginning of the experiment until the final observation at 20 minutes. This is a 14.7% change over 20 minutes with a P value (<0.001), exemplifying a statistically significant change in scroll width. CONCLUSIONS: Temperature did not have any significant effect over scroll tightness, but scroll tightness decreased with collagenase exposure.
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Queratoplastia Endotelial de la Lámina Limitante Posterior , Recuento de Células , Colagenasas , Lámina Limitante Posterior/cirugía , Queratoplastia Endotelial de la Lámina Limitante Posterior/métodos , Endotelio Corneal/trasplante , Humanos , Estudios RetrospectivosRESUMEN
Fungal keratitis is a devastating and difficult-to-treat ocular infection with high morbidity. Understanding geographic microbiological and clinical trends helps to guide rapid and effective treatment. We therefore report the characteristics and outcomes of fungal keratitis in Toronto,ON Canada, over a 20-year period. An electronic search of microbiology records at University Health Network, Toronto, ON, Canada identified all patients with positive corneal fungal culture over a 20-year period seen at our tertiary referral cornea practice. Review of corresponding patient charts identified demographic and microbiological details, clinical course, treatment regimen, and final outcomes associated with each episode of culture-positive fungal keratitis. A total of 46 patients with 51 discrete fungal keratitis episodes were included. Five patients experienced recurrent fungal keratitis. Candida species accounted for 60.8% of positive fungal cultures, followed by Filamentous species at 35.3%. Preferred initial anti-fungal treatment was topical amphotericin at 36.7% followed by topical voriconazole at 32.6%. Surgical intervention was required in 48.9% with therapeutic penetrating keratoplasty being the most common procedure (22.4%). Final visual acuity (VA) of <20/200 was attributed to 58% of patients in this study. Risk factors for poor outcomes included poor VA, topical steroid use at presentation, Candida involvement, history of ocular surface disease, organic ocular trauma, or prior corneal transplantation. Candida is the most frequent keratomycotic pathogen in Toronto. Risk factors for poor visual outcome include prior corneal transplantation, ocular surface disease/trauma, or pre-existing topical steroid use. Early suspicion, diagnosis and treatment are paramount for best clinical outcomes. LAY SUMMARY: Fungal keratitis can cause severe vision loss without effective treatment. In Toronto, Candida had been the most common species over a 20-year period. Poor clinical outcome was associated with low presenting visual acuity, previous corneal transplant, topical steroid use, trauma, and Candida involvement.
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Úlcera de la Córnea , Infecciones Fúngicas del Ojo , Animales , Antifúngicos/uso terapéutico , Candida , Córnea/microbiología , Úlcera de la Córnea/microbiología , Úlcera de la Córnea/veterinaria , Infecciones Fúngicas del Ojo/diagnóstico , Infecciones Fúngicas del Ojo/tratamiento farmacológico , Infecciones Fúngicas del Ojo/epidemiología , Infecciones Fúngicas del Ojo/veterinaria , Humanos , Estudios Retrospectivos , Voriconazol/uso terapéuticoRESUMEN
PURPOSE: We describe the first known use of telementoring in corneal surgery and technology combining a 3-dimensional microscope system, 5G live streaming technology, group chat software, and a virtual reality headset for intercontinental surgical supervision. METHODS: Three surgeons in Toronto were proctored by a surgeon in Israel in the implantation of a novel keratoprosthesis device (CorNeat KPro; Ra'anana, Israel) into cadaver eyes. In Toronto, the NGENUITY platform (Alcon) transmitted high-definition, 3-dimensional images to the proctor in Israel who viewed the live video through a GOOVIS Virtual Reality headset with subsecond latency. This was made possible by the LiveU technology (Hackensack, NJ), which is a portable device to increase the bandwidth of transmission. The primary outcome was the successful completion of CorNeat KPro implantation. After each procedure, all surgeons completed a Likert scale questionnaire that assessed opinions on telementoring. RESULTS: All participants implanted the CorNeat KPro device. There was significant satisfaction reported. A total cumulative score from the questionnaire was 149 of 150 from the operating surgeons, with a score of 135 of 150 by the proctor. All felt that there was excellent AV quality with no lag time and recommended the technology. CONCLUSIONS: Telementoring is a promising tool that can traverse large distances for ophthalmic education.
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Córnea/cirugía , Enfermedades de la Córnea/cirugía , Educación de Postgrado en Medicina/métodos , Procedimientos Quirúrgicos Oftalmológicos/educación , Oftalmólogos/educación , Oftalmología/educación , Telemedicina/métodos , Cadáver , Humanos , Prótesis e ImplantesRESUMEN
PURPOSE: To investigate outcomes of femtosecond laser (FL)-assisted cataract surgery (FLACS) and refractive lens exchange (RLE) in patients with prior radial keratotomy (RK). SETTING: Single clinical practice. DESIGN: Retrospective observational case series. METHODS: All patients with prior RK undergoing FLACS- or FL-assisted RLE surgeries over a 6-year period were reviewed. Inclusion criteria were diurnal stability and stable manifest refraction. Exclusion criteria were any other incisional corneal surgery, macular or glaucomatous pathology, or vision loss due to any other cause. Data collected included demographics, visual acuity, laser settings, and complications. Main outcome measures were intraoperative and postoperative complications and visual outcomes. Safety and efficacy indices were evaluated. RESULTS: 16 eyes of 9 patients were included. Mean age and follow-up time were 59.9 ± 9.9 years (range 44 to 75 years) and 3.3 ± 2.5 months, respectively. The mean number of RK cuts was 11.8 ± 5.3 (range 8 to 20). Mean preoperative uncorrected (UDVA) and corrected distance visual acuity (CDVA) were 0.9 ± 0.4 logMAR (Snellen 20/160) and 0.2 ± 0.3 logMAR (Snellen 20/30), respectively. 2 intraoperative anterior capsule tears were identified. 1 postoperative intraocular lens dislocation occurred. Postoperatively, the mean UDVA and CDVA were 0.2 ± 0.2 logMAR (20/30) and 0.1 ± 0.1 logMAR (20/25), respectively. The safety index was 1.6, and the efficacy index was 1.2. CONCLUSIONS: FLACS- or FL-assisted RLE surgery in RK patients has a high risk for anterior capsule tear and should be avoided. Thickened incisional scars are potential sources of incomplete laser penetrance. Toric lens implantation in RK eyes provide unpredictable astigmatic correction and should also be avoided.
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Catarata , Queratotomía Radial , Facoemulsificación , Adulto , Anciano , Catarata/complicaciones , Humanos , Rayos Láser , Persona de Mediana Edad , Refracción Ocular , Estudios RetrospectivosRESUMEN
PURPOSE: To assess the outcomes of Descemet membrane endothelial keratoplasty (DMEK) in patients with ocular hypotony after glaucoma surgery. DESIGN: retrospective case series. METHODS: Setting: Multicenter retrospective case series. PATIENTS/INTERVENTION: Hypotonic eyes with prior glaucoma surgery that underwent DMEK between January 2013 and July 2019 in Israel (2 centers) and Canada (1 center). MAIN OUTCOME MEASURES: Pre/postoperative corrected distance visual acuity, complications, 3- to 6-month endothelial cell loss, and intraocular pressure (IOP). RESULTS: The study included 11 DMEK procedures performed in 10 eyes of 4 males and 6 females aged 65-84 years. Indications for DMEK included 7 cases of pseudophakic bullous keratopathy, 2 cases of failed DMEK, and 1 case of failed Descemet stripping automated endothelial keratoplasty. All patients had at least 1 previous trabeculectomy operation. One patient had 2 trabeculectomy procedures and 1 tube placement procedure. Two patients had 1 previous trabeculectomy and 1 tube placement procedure. The corrected distance visual acuity improved significantly from 1.52 ± 0.68 logarithm of minimal angle of resolution preoperatively to 0.49 ± 0.32 logarithm of minimal angle of resolution 3 months postoperatively (P < .001). Rebubbling occurred in 3 of 11 procedures (27%). Endothelial cell loss 6-12 months postoperatively was 60% ± 16% (range, 41%-89%). At the last follow-up visit, 6 of 11 (54%) of the grafts were clear. The remaining 5 grafts failed at 1-4 years postoperatively. The preoperative IOP was 5.1 ± 1.6 mm Hg (range, 1-7 mm Hg). In all but one patient, the postoperative IOP did not increase to more than 13 mm Hg. In 2 cases, the IOP decreased from 5 and 7 mm Hg preoperatively to 1 mm Hg 1 year postoperatively. CONCLUSION: DMEK is a valid procedure for the treatment of corneal edema in hypotonic eyes after glaucoma procedures. These eyes benefit from improvement in vision after DMEK.
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Queratoplastia Endotelial de la Lámina Limitante Posterior , Glaucoma , Hipotensión Ocular , Lámina Limitante Posterior , Endotelio Corneal , Femenino , Glaucoma/cirugía , Humanos , Masculino , Estudios RetrospectivosRESUMEN
PURPOSE: To report outcomes of a sutureless dehydrated amniotic membrane for persistent epithelial defects (PED). METHODS: This retrospective study included consecutive patients with a PED (⩾14 days) treated with a sutureless dehydrated amniotic membrane and bandage contact lens (BCL). Included were patients with an epithelial defect that did not respond to treatment with a BCL. Excluded were patients with a follow-up time of less than 3 months. RESULTS: Nine eyes of eight patients with a mean age of 54.6 ± 10.9 years (range 38-73 years) were included in this study. The main etiology of the PED was limbal stem cell deficiency (n = 5/9) due to Stevens-Johnson Syndrome (n = 2/5), glaucoma procedures (n = 1/5), graft-versus-host disease (n = 1/5) and severe allergic reaction (n = 1/5). Additional etiologies included neurotrophic cornea (n = 2/9), post keratoplasty and severe dry eye disease (n = 2/9). Time from PED presentation to amnion treatment was 65.9 ± 60.6 days (range 15-189 days) with the area of the PED being 11.0 ± 12.2 mm2 (range 1.0-36.0 mm2). The amnion was absorbed within 2 weeks in 100% of the cases. Following insertion of the amnion, resolution of the PED was achieved in 8/9 eyes (89%) without the need for additional interventions within 17.8 ± 9.6 days (range 7-35 days). LogMAR BCVA improved from 0.94 ± 0.88 to 0.37 ± 0.25 (p = 0.036) with no complications or recurrences recorded. CONCLUSIONS: Sutureless dehydrated amniotic membrane achieved resolution of PEDs secondary to various etiologies in 89% of eyes with a significant improvement in vision demonstrated. Further studies are needed to assess long term safety and effectiveness.
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PURPOSE: Vitrectomized eyes pose a technical challenge when performing endothelial keratoplasty (EK). The aim of the study was to compare outcomes of Descemet membrane endothelial keratoplasty (DMEK) and Descemet stripping automated endothelial keratoplasty (DSAEK) in complex eyes undergoing pars plana vitrectomy (PPV) prior to or during surgery. METHODS: This retrospective study included consecutive eyes that underwent pars plana infusion-assisted DMEK or pull-through DSAEK which underwent PPV prior to or during the EK at a tertiary center. Included were eyes with at least 1-year follow-up. The main outcome measures were best-corrected visual acuity (BCVA) and serious adverse events. RESULTS: Fifty-two eyes (n = 52) with a mean follow-up time of 24.6 ± 7.4 months were included. Both groups were similar in terms of baseline characteristics although the DMEK group had a significantly larger proportion of Fuchs' patients (p = .009). There was no significant difference in postoperative logMAR BCVA between groups at each visit (p > .05 for all). There was a significantly higher proportion of overall serious adverse events (50.0% versus 15.4%, p = .02), retinal detachments (19.2% versus 0.0%, p = .05) and cystoid macular edema (23.1% versus 0.0%, p = .02) following DMEK. Graft detachment occurred more often following DMEK (53.9% versus 11.5%, p = .001) with no significant difference in rebubbling rates (23.1% versus 11.5%, p = .27). CONCLUSIONS: A significant and similar improvement in BCVA was achieved following DMEK and DSAEK in complex vitrectomized eyes. Patients should be advised regarding the higher rates of potential serious complications associated with a pars plana infusion DMEK in this situation.
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Córnea/patología , Pérdida de Celulas Endoteliales de la Córnea/cirugía , Complicaciones Posoperatorias/cirugía , Vitrectomía/efectos adversos , Adulto , Anciano , Anciano de 80 o más Años , Recuento de Células , Córnea/cirugía , Pérdida de Celulas Endoteliales de la Córnea/diagnóstico , Pérdida de Celulas Endoteliales de la Córnea/etiología , Queratoplastia Endotelial de la Lámina Limitante Posterior , Femenino , Estudios de Seguimiento , Supervivencia de Injerto , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/diagnóstico , Estudios Retrospectivos , Factores de Tiempo , Resultado del TratamientoRESUMEN
PURPOSE: To evaluate repeat Descemet membrane endothelial keratoplasty (re-DMEK) success rates and to identify risk factors for re-DMEK failure. DESIGN: Retrospective case series. METHODS: Settings: Institutional. PATIENTS AND INTERVENTIONS: A chart review was performed, including all eyes with primary DMEK failure that underwent re-DMEK between 2013 and 2019 at the Toronto Western Hospital and the Kensington Eye Institute (Toronto, Ontario, Canada) and had at least 6 months of follow-up. MAIN OUTCOME MEASURE: Predicting factors for re-DMEK outcome. RESULTS: Of 590 consecutive DMEK surgeries, 40 eyes (6.7%) were identified for having a secondary DMEK surgery after primary DMEK failure. Etiologies for primary DMEK were Fuchs endothelial corneal dystrophy (32.5%), pseudophakic bullous keratopathy (35%), previous failed graft (27.5%), and other indications (5%). Fifty-five percent of the cohort were categorized as having a complicated anterior segment including 11 eyes with previous glaucoma surgery, 7 eyes post-penetrating keratoplasty, 4 eyes post-Descemet stripping automated endothelial keratoplasty, 3 eyes peripheral anterior synechia, 3 eyes previous pars plana vitrectomy, 2 eyes aphakia, and 1 eye each with aniridia, anterior chamber intraocular lens, and iris-fixated intraocular lens. Re-DMEK failure was documented in 12 eyes (30%) of the entire cohort. The risk factor for re-DMEK failure was the presence of a complicated anterior segment (P = .01, odds ratio = 17.0 [95% confidence interval: 1.92-150.85]), with 50% re-DMEK failure rate in this subgroup. CONCLUSION: Re-DMEK is a viable option for cases of primary DMEK failure, especially for eyes with Fuchs endothelial corneal dystrophy as the indication for primary DMEK without other ocular morbidities; however, eyes categorized with a complicated anterior segment had high re-DMEK failure rates..
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Pérdida de Celulas Endoteliales de la Córnea/etiología , Queratoplastia Endotelial de la Lámina Limitante Posterior/efectos adversos , Rechazo de Injerto/etiología , Anciano , Anciano de 80 o más Años , Vesícula/cirugía , Enfermedades de la Córnea/cirugía , Femenino , Estudios de Seguimiento , Distrofia Endotelial de Fuchs/cirugía , Supervivencia de Injerto/fisiología , Humanos , Masculino , Persona de Mediana Edad , Recurrencia , Reoperación , Estudios Retrospectivos , Factores de Riesgo , Agudeza Visual/fisiologíaRESUMEN
PURPOSE: To compare the outcomes of femtosecond astigmatic keratotomy (FSAK) and manual astigmatic keratotomy (AK) in treatment of postkeratoplasty astigmatism. METHODS: A retrospective, comparative, pairwise-matched case series including 150 patients who underwent either FSAK (n = 75) or manual AK (n = 75) for the treatment of astigmatism (>3.00 D) following penetrating keratoplasty or deep anterior lamellar keratoplasty. Pairwise matching for baseline variables (age, visual acuity and astigmatism) was performed. RESULTS: Mean age was 57.5 ± 16.0 years. The FSAK group had significantly better postoperative best-corrected visual acuity (BCVA) (p = 0.010), uncorrected visual acuity (UCVA) (p = 0.049), corneal astigmatism (p = 0.020) and manifest astigmatism (p < 0.001) compared with the manual AK group. Gain of ≥3 lines in BCVA (logMAR) was seen in five eyes (6.7%) and 21 eyes (28.0%) in manual AK and FSAK, respectively (p = 0.005). Alpins vector analysis showed lower (closer to 0) index of success (0.50 ± 0.24 and 0.79 ± 0.48, p < 0.001) and higher (closer to 1) correction index (0.94 ± 0.45 and 0.74 ± 0.55, p = 0.020) in FSAK compared with manual AK. Corneal and manifest astigmatism improved significantly in both groups, while BCVA and UCVA improved significantly in FSAK only. Repeat AK rate was 32% (24 eyes) in manual AK and 4% (three eyes) in FSAK (p < 0.001). Overcorrection-related re-suturing rate was 0% in manual AK and 8% (six eyes) in FSAK (p = 0.037). There was one microperforation (1.3%) in FSAK, and there were no occurrences of graft dehiscence, infectious keratitis or graft rejection. CONCLUSIONS: Both manual AK and FSAK were safe and effective in reducing postkeratoplasty astigmatism. FSAK had superior visual and keratometric outcomes compared with manual AK.
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Astigmatismo/cirugía , Córnea/cirugía , Queratoplastia Penetrante/efectos adversos , Queratotomía Radial/métodos , Láseres de Excímeros/uso terapéutico , Refracción Ocular , Agudeza Visual , Astigmatismo/diagnóstico , Astigmatismo/etiología , Córnea/diagnóstico por imagen , Enfermedades de la Córnea/cirugía , Topografía de la Córnea , Femenino , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias , Reoperación , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
OBJECTIVE: To present outcomes of Descemet membrane endothelial keratoplasty (DMEK) in eyes with prior trabeculectomy or a glaucoma drainage device (GDD). METHODS: A retrospective case series, including patients that had previously undergone trabeculectomy and/or GDD implantation, who later underwent DMEK between 2013 and 2016 at Toronto Western Hospital and the Kensington Eye Institute. Outcome measures: best spectacle-corrected visual acuity (BSCVA), endothelial cell (EC) density, intraoperative and postoperative complications. RESULTS: Twenty-seven eyes of 27 patients were included. All DMEK procedures were uneventful. Mean follow-up time was 14.6 ± 6.1 months. In eyes with no visually limiting comorbidities (n = 16), BSCVA improved from 1.34 ± 0.65 logMAR (Snellen equivalent ~20/440) preoperatively to 0.51 ± 0.24 logMAR (Snellen equivalent ~20/65) and 0.50 ± 0.33 logMAR (Snellen equivalent ~20/65) at 6 and 12 months, respectively (p < 0.001 for both). In eyes with visually limiting comorbidities (n = 11), BSCVA improved from 1.92 ± 0.72 logMAR (Snellen equivalent ~20/1665) preoperatively to 1.43 ± 0.83 logMAR (Snellen equivalent ~20/540) and 1.37 ± 0.99 logMAR (Snellen equivalent ~20/470) at 6 and 12 months, respectively (p = 0.008 and p = 0.037).Graft detachment rate was 24.1% and rebubble rate was 17.2%. Primary and secondary graft failure rates were 3.7% and 10.3%, respectively. Rejection rate was 17.2%. EC-loss rate at 6 months and 12 months was 36.7% and 50.5%, respectively. CONCLUSIONS: DMEK performed in eyes with previous trabeculectomy or a GDD is more challenging than conventional DMEK, but has good outcomes. Higher rates of graft rejection and secondary graft failure in this setting should be further evaluated in long-term studies.