Topical tacrolimus for high-risk corneal transplantation: a randomized, clinical trial.

BACKGROUND: The prevalence of rejection is 10-30% in penetrating keratoplasty (PKP) case, and the rate is higher in cases of high-risk patients. Although using topical corticosteroids is a standard method for management the rejection of post-PKP patients, it may not be sufficiently potent in high-risk patients. Topical administration of tacrolimus (TAC) may be effective in suppression rejection after corneal transplantation. This study aimed to investigate the efficacy and safety of topical TAC in high-risk PKP patients in Japan. METHODS: This study was a single centre, single-blinded, randomized controlled trial. Patients with a history of PKP, graft rejection, atopic dermatitis, or deep corneal neovascularisation who underwent PKP were enrolled. They were randomly assigned to receive 0.1% TAC ophthalmic suspension or artificial tear (AT) up to week 52 after surgery. All participants received 0.1% betamethasone up to week 13 after surgery then they received 0.1% fluorometholone up to week 52. The incidence of immunological rejection during the observation period was the main outcome measure in this study. RESULTS: Thirty patients were enrolled in this study, and 12 eyes in the TAC group and 13 eyes in the AT group completed the study, respectively. Five out of 30 patients discontinued participation after providing informed consent. No serious adverse effects were developed in patients who received 0.1% TAC ophthalmic suspension. No rejection episodes occurred in the TAC group, while one eye in the AT group had rejection. Graft clarity, best spectacle-corrected visual acuity, intraocular pressure, and corneal endothelial cell density were not significantly different between the TAC and AT groups. CONCLUSION: Our results demonstrated that good tolerability of 0.1% TAC ophthalmic suspension. However, we failed to demonstrate its efficacy in preventing immunological rejection in high-risk patients undergoing PKP. TRIAL REGISTRATION: This study was first registered in the University Hospital Medical Information Network (UMIN000029669, Date of registration: November 1, 2017). With the enforcement of the Clinical Trial Act in Japan, the study re-registered in the Japan Registry of Clinical Trials (jRCTs031180342, Date of registration: March 18, 2019).

Clinical Trial of Autologous Cultivated Limbal Epithelial Cell Sheet Transplantation for Patients with Limbal Stem Cell Deficiency.

PURPOSE: To confirm the efficacy and safety of Good Manufacturing Practice (GMP)-compliant autologous cultivated limbal epithelial cell sheets in government-controlled clinical trials that adhered to Good Clinical Practice stipulations for patients with unilateral limbal stem cell deficiency (LSCD). DESIGN: A prospective, multicenter, open-label, uncontrolled, single-arm clinical trial. PARTICIPANTS: Ten consecutive eyes of 10 patients with unilateral LSCD were followed for 2 years after surgery. Preoperative LSCD stage was IIB in 4 eyes and III in 6 eyes. METHODS: A limbal tissue biopsy was obtained from the healthy eye, after which limbal stem cells were dissociated and cultivated on temperature-responsive culture surfaces. All cell sheets were fabricated in a GMP-grade facility under established standard operating procedures. Cell sheets were evaluated using defined shipment criteria before transplantation, and only those that met the criteria were used. The cell sheet was transplanted onto each of the patients' diseased eye after removing the conjunctival scar tissue that covered the corneal surface. The severity of LSCD was determined according to a staging method agreed on by global consensus, with eyes evaluated as being in stages IA-C representing successful corneal epithelial reconstruction. Diagnosis and staging of LSCD were determined by the trial's Eligibility Judgment Committee and Effect Assessment Committee using slit-lamp photographs including fluorescein staining. Both committees comprised 2 or 3 third-party cornea specialists, who were provided with information anonymously and randomly. MAIN OUTCOME MEASURE: Corneal epithelial reconstruction rate was the primary end point. RESULTS: Corneal epithelial reconstruction was successful in 6 of 10 eyes (60%) 1 year postoperatively and was significantly higher than the 15% clinically significant efficacy rate achieved by allogeneic limbal transplantation. The reconstruction rate was 70% of eyes 2 years postoperatively. Additionally, improvements in visual acuity were noted in 50% and 60% of eyes at 1 and 2 years, respectively. No clinically significant transplantation-related adverse events were observed. CONCLUSIONS: The efficacy and safety of cultivated limbal epithelial cell sheet transplantation were thus confirmed, and the cell sheet, named "Nepic," is now approved as a cellular and tissue-based product in Japan. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Continuous acellular material accumulation in the anterior chamber associated with corneal endothelial changes.

This case series included two healthy adults who showed continuous production of acellular materials in the anterior chamber without inflammation. The materials were membrane-like in case 1 and amorphous in case 2; they gradually changed shape and location over several years. During follow-up, there were no changes in vision, the iris or the chamber angle. Anterior segment optical coherence tomography confirmed the attachment of the membrane to the corneal endothelium. Specular microscopy showed normal endothelial counting with reversal of the normal light/dark patterns that occasionally returned to normal appearances. Although acellular materials were observed unilaterally in both cases, abnormal endothelial images were noted in both eyes of case 1. Histopathological examinations demonstrated the absence of cellular components with negative immunostaining for collagen IV, vimentin and α-smooth muscle actin. Serial ophthalmic examinations and histopathological findings suggest that the production of acellular material was associated with alterations of the corneal endothelium.

Japanese guidelines for allergic conjunctival diseases 2020.

The definition, classification, pathogenesis, test methods, clinical findings, criteria for diagnosis, and therapies of allergic conjunctival disease are summarized based on the Guidelines for Clinical Management of Allergic Conjunctival Disease 2019. Allergic conjunctival disease is defined as "a conjunctival inflammatory disease associated with a Type I allergy accompanied by some subjective or objective symptoms." Allergic conjunctival disease is classified into allergic conjunctivitis, atopic keratoconjunctivitis, vernal keratoconjunctivitis, and giant papillary conjunctivitis. Representative subjective symptoms include ocular itching, hyperemia, and lacrimation, whereas objective symptoms include conjunctival hyperemia, swelling, folliculosis, and papillae. Patients with vernal keratoconjunctivitis, which is characterized by conjunctival proliferative changes called giant papilla accompanied by varying extents of corneal lesion, such as corneal erosion and shield ulcer, complain of foreign body sensation, ocular pain, and photophobia. In the diagnosis of allergic conjunctival diseases, it is required that type I allergic diathesis is present, along with subjective and objective symptoms accompanying allergic inflammation. The diagnosis is ensured by proving a type I allergic reaction in the conjunctiva. Given that the first-line drug for the treatment of allergic conjunctival disease is an antiallergic eye drop, a steroid eye drop will be selected in accordance with the severity. In the treatment of vernal keratoconjunctivitis, an immunosuppressive eye drop will be concomitantly used with the abovementioned drugs.

Exophiala lecanii-corni keratitis presenting as a serpiginous pigmented superficial lesion: a case report.

RATIONALE: Patients with bullous keratopathy (BK) treated by Descemet stripping automated endothelial keratoplasty (DSAEK) have a compromised cornea, due to the administration of topical steroid, postsurgical use of contact lenses, and impaired barrier function of the corneal epithelium by BK. We report a case of Exophiala lecanii-corni (E lecanii-corni) keratitis presenting as a serpiginous pigmented superficial lesion after DSAEK. PATIENT CONCERNS: An 81-year-old woman who had undergone cataract surgeries, suffered from decreased vision in the left eye. She was diagnosed BK and she underwent DSAEK. Two months after DSAEK, a pigmented superficial lesion developed on the left cornea. The lesion migrated and recurred repeatedly and she was referred to our department. Best corrected vision was 20/220. DIAGNOSES: Light microscopy of a corneal scraping revealed branching fungal hyphae. Fungal culture showed growth of a black colony, identified as E lecanii-corni by ribosomal DNA sequencing. INTERVENTIONS: We started topical treatment with 1% voriconazole and 1.5% levofloxacin. Antifungal susceptibility testing showed that the minimum inhibitory concentration of voriconazole was 0.06 µg/mL. OUTCOMES: The lesion scarred after treatment for 3 months, and left best corrected vision improved to 20/40. LESSONS: Genus Exophiala is known as 1 of the "black molds" and a cause of chromomycosis. This is the first description of E lecanii-corni keratitis, and pigmented corneal epithelial lesions may be characteristic of this fungal genus.

Correlations between tear fluid and aqueous humor cytokine levels in bullous keratopathy.

PURPOSE: To evaluate the correlation between tear fluid and aqueous humor (AqH) cytokine levels in eyes with bullous keratopathy (BK) and with normal endothelium. METHODS: This prospective consecutive case-series study included 71 eyes of 71 patients: 31 eyes with BK, 18 eyes with non-BK corneal diseases, and 22 eyes with uncomplicated cataract (healthy controls). Total protein and cytokine (interleukin [IL]-1α, IL-1ß, IL-4, IL-6, IL-8, IL-10, MIP-1α, MIP-1ß, monocyte chemotactic protein [MCP]-1, E-selectin, P-selectin, soluble intercellular adhesion molecule [sICAM]-1, and IP-10) levels in the tear fluid and AqH were measured using multiplex beads immunoassay. The correlations between tear and AqH cytokine levels were assessed. RESULTS: The AqH protein level was significantly higher in BK eyes (1.09 ± 0.08 mg/mL) than in non-BK (0.63 ± 0.11, P = 0.0004) and healthy control (0.62 ± 0.06, P = 0.0002) eyes. The tear total protein and IL-4 levels were significantly higher in the BK group compared to healthy controls (P = 0.0374 and 0.0032, respectively). The AqH IL-8 and sICAM-1 levels were significantly higher in the BK group compared to controls (P = 0.0001 and 0.0083, respectively). In BK eyes, the tear IL-4 level was significantly correlated with the MCP-1(r = 0.563, P = 0.001) and total protein (r = 0.589, P = 0.001) AqH levels. The tear IL-8 level was significantly correlated with the MCP-1(r = 0.598, p = 0.001) and IL-4 (r = 0.781, p < 0.0001) AqH levels in BK eyes. However, no significant correlations were found between tear and AqH cytokine levels in non-BK and healthy controls eyes. CONCLUSIONS: The tear cytokine levels are correlated with those of AqH only in BK, but not in non-BK and healthy controls.

Long-term outcomes of cultivated cell sheet transplantation for treating total limbal stem cell deficiency.

PURPOSE: This study was conducted to determine the long-term outcomes of cultivated cell sheet transplantation (CCST), and to clarify risk factors that affected the outcomes. METHODS: We retrospectively analyzed the medical charts and photographs of 246 consecutive surgeries (162 eyes from 139 patients) that used CCST for treating total limbal stem cell deficiency. Deficiency types included Stevens-Johnson syndrome (SJS) or toxic epidermal necrolysis (SJS/TEN; n = 80), ocular surface burns (Burn; n = 75), ocular cicatricial pemphigoid (OCP) or pseudo-OCP (n = 58), and others (n = 33). The methods of CCST included 103 cultivated limbal epithelial transplantations (28 autologous, 62 allogeneic, and 13 living-related relatives), and 143 cultivated oral mucosal epithelial transplantations. We analyzed the rate of successful ocular surface reconstruction, clear corneas, and best-corrected visual acuity equal to or better than 20/200. RESULTS: With a mean observation period of 357 weeks, successful ocular surface reconstruction and clear corneas at last visit were achieved in 65.1% of the patients. Corrected visual acuity equal to or better than 20/200 was achieved in 19.0% of the patients. Eyes with SJS/TEN exhibited worse outcomes compared with the Burn group. Postoperative complications included corneal ulcerations or perforations (18.3%), glaucoma (13.8%), and infections (8.5%). Multivariate analyses using the logistic mixed-effects model indicated that the presence of preoperative corneal epithelial defects was a significant risk factor for postoperative failure. CONCLUSIONS: In this series, the success rate of CCST after a mean observation period of 357 weeks was 65.1%, and preoperative epithelial defect was the most relevant risk factor.

The Effect of Cytokine-Stimulation and Pharmacologic Intervention on PGE2 Production in Primary Human Conjunctival and Corneal Cells.

We studied the production of PGE2 by human conjunctival and corneal cells in response to inflammation, and reduction of inflammation with non-steroidal anti-inflammatory drugs. Primary cultures of human conjunctival epithelial cells, fibroblasts, corneal epithelial cells, and keratocytes were incubated with IL-4 and TNF-α. PGE2 and COX-2 levels were analyzed. Effects of anti-inflammatory and anti-immune drugs on PGE2 production were also investigated. IL-4 and TNF-α induced the generation of PGE2 and COX-2 in conjunctival and corneal cells. Epithelial PGE2 production was significantly lower than in keratocytes and fibroblasts, which was down-regulated by aspirin. IL-4 and TNF-α enhanced the inflammatory response via prostaglandin production which contributed to ocular surface inflammation. Prostaglandin production was higher in stromal cells than epithelial cells. These results suggest that the epithelial barrier disruption may contribute to ocular allergic inflammation by the PGE2 production from stromal cells. Moreover, NSAIDs were effective in suppressing PGE2 production in our experiment.

Air pollution significantly associated with severe ocular allergic inflammatory diseases.

Ambient air pollution is a well-recognized risk for various diseases including asthma and heart diseases. However, it remains unclear whether air pollution may also be a risk of ocular allergic diseases. Using a web-based, nation-wide, cross-sectional study design, we examined whether the level of ambient air pollution is significantly associated with the prevalence of ocular allergic diseases. A web-based questionnaire was posted to invite the participants who are members of the Japan Ophthalmologist Association and their family members. The answers from 3004 respondents were used to determine whether there were significant associations between the level of the pollutants and the prevalence of ocular allergic diseases. The study period was between March to May 2017. The data of the air pollutants during 2012 to 2016 were obtained from the National Institute for Environmental Studies. The prevalence of allergic diseases was calculated by post stratification and examined for significant associations with the level of pollutants using multiple logistic regression analyses. The prevalence of seasonal allergic conjunctivitis, perennial allergic conjunctivitis, atopic keratoconjunctivitis (AKC), and vernal keratoconjunctivitis (VKC) in Japan was 45.4%, 14.0%, 5.3%, and 1.2%, respectively. The high prevalence of the severe forms of allergic conjunctivitis, including AKC and VKC, were significantly associated with the levels of the air pollutants. The prevalence of AKC was significantly associated with the levels of NO2 with an odds ratio (OR) of 1.23 (per quintile). The prevalence of VKC was significantly associated with the levels of NOx and PM10 with ORs of 1.72 and 1.54 respectively. The significant associations between the prevalence of AKC and VKC and the levels of air pollutants indicate that clinicians need to be aware that air pollutants may pose serious risks of vision threatening severe ocular allergy.

Effects of Amniotic Membrane-Derived Fibroblast Supernatant on Corneal Epithelium.

Purpose: To evaluate the effects of human amniotic membrane-derived fibroblast (AMF) cell supernatant (AMF-sup) on corneal epithelium. Methods: The phenotype of AMF cells was analyzed by flow cytometry using cell-surface markers. AMF cells were also induced to form osteoblasts and neural cells, and cell phenotypes were observed by staining and RT-PCR. Cultivated human corneal limbal epithelial sheets generated using AMF-sup were analyzed using immunohistochemistry and colony-forming efficiency, and the wound healing of epithelial defects was observed using a tissue-punch method. The effects of instillation of each supernatant in a rabbit corneal epithelial wound healing model were compared. Results: Mesenchymal stem cell (CD29, CD44, CD73, and CD90) and neural crest (CD49d and CD56) markers were expressed on the AMF cell surface. Following induction of differentiation, isolated AMF cells showed characteristics of osteoblasts and neural cells. Application of AMF-sup resulted in maintenance of the limbal epithelial phenotype and immature state, and significantly promoted wound healing in cultivated human corneal limbal epithelial sheets (P < 0.05) and rabbit corneal epithelium (P < 0.05) compared with the control. Conclusions: These data suggest that AMF cells have multi-differentiation potential, and that AMF-sup is effective in maintaining the limbal epithelial phenotype and promoting corneal epithelial wound healing, which may be of value in ocular surface reconstruction.

Descemet stripping automated endothelial keratoplasty performed by trainees.

PURPOSE: To assess the surgical outcomes of Descemet stripping automated endothelial keratoplasty (DSAEK) performed by trainees. STUDY DESIGN: Retrospective, case control comparative study. METHODS: This study compared cases performed by trainees with those performed by an experienced surgeon. First 10 cases of DSAEK performed by trainees with more than 6 months follow-up periods were recruited. The surgical outcomes of DSAEK performed by the trainees (Trainee group) were compared with disease-matched pairs of cases performed by an experienced surgeon (Experienced group). Graft clarity, best spectacle-corrected visual acuity, corneal endothelial cell density, and incidence of intra- or post-operative complications were studied. RESULTS: Forty-one pairs were recruited. The graft clarity rate was not different between the Trainee and Experienced groups, with 95.1% and 97.6%, respectively, maintaining clear grafts at 12 months postoperatively. Trainee best spectacle corrected visual acuity was significantly worse at 6 and 12 months postoperatively compared with the Experienced group, and percent decreases in corneal endothelial density was more in the Trainee group at 3 months following surgery (P = 0.0029). While intra- or late post-operative complication rates were similar in both groups, incidences of early post-operative complications such as double chamber formation or pupillary block were observed more frequently in the Trainee group than in the Experienced group (P = 0.049). CONCLUSION: DSAEK can be performed relatively safely by training physicians with careful preparation and supervision by attending physicians. However, careful case selection and education on management of air injected in the anterior chamber seemed to be a key to long-term success.

Preoperative Aqueous Cytokine Levels are Associated With Endothelial Cell Loss After Descemet's Stripping Automated Endothelial Keratoplasty.

Purpose: To evaluate the association between endothelial cell density (ECD) after Descemet's stripping automated endothelial keratoplasty (DSAEK) and preoperative cytokine levels in the aqueous humor (AqH). Methods: This prospective consecutive case series included 97 consecutive patients who underwent DSAEK (64 eyes) or cataract surgery (33 eyes). AqH samples were collected at the beginning of each surgery. The levels of cytokines (IL-1α, IL-1ß, IL-4, IL-6, IL-8, IL-10, IL-12p70, IL-13, IL-17A, IFN-α, IFN-γ, monocyte chemotactic protein [MCP]-1, E-selectin, P-selectin, and soluble intercellular adhesion molecule [sICAM]-1) in the AqH were measured by multiplex beads immunoassay. The correlations between preoperative aqueous cytokine levels and the ECD at 12 months after DSAEK were analyzed. Results: The ECD decreased from 2747 ± 259 cells/mm2 in the donor graft to 1235 ± 607 cells/mm2 at 12 months after DSAEK. In all subjects undergoing DSAEK, the postoperative ECD at 12 months was significantly correlated with the preoperative levels of MCP-1 (r = -0.467, 95% confidence interval [CI]: -0.650 to -0.222, P = 0.0003). In an analysis excluding Fuchs endothelial corneal dystrophy (11 eyes), the ECD at 12 months after DSAEK was significantly correlated with preoperative levels of IL-17A (r = -0.635, 95% CI: -0.819 to -0.319, P = 0.0004), MCP-1 (r = -0.605, 95% CI: -0.779 to -0.345, P < 0.0001), IFN-γ (r = -0.633, 95% CI: -0.796 to -0.385, P < 0.0001), E-selectin (r = -0.516, 95% CI: -0.756 to -0.276, P = 0.0004), and sICAM-1 (r = -0.537, 95% CI: -0.735 to -0.253, P = 0.0005). Conclusions: Higher preoperative levels of IL-17A, MCP-1, IFN-γ, E-selectin, and sICAM-1 in the AqH were associated with lower ECD after DSAEK for bullous keratopathy.

Decreased Visual Acuity by an Irregular Corneal Posterior Surface After Repeat Descemet Stripping Automated Endothelial Keratoplasty.

PURPOSE: To investigate the impact of higher-order aberrations (HOAs) on visual acuity after repeat Descemet stripping automated endothelial keratoplasty (DSAEK) in the same eyes. METHODS: This retrospective comparative case series includes 23 patients who underwent DSAEK twice in the same eyes (46 DSAEK in total). We evaluated the HOAs of the anterior and posterior corneal surfaces, and total cornea using the Fourier analysis data from anterior segment optical coherence tomography. Eyes were divided into one of the following groups, based on the improvement and decline in the best-corrected visual acuity (BCVA) after repeat DSAEK; group A: 12 eyes with an improvement ≥ 2 lines, group B: 12 eyes with a decline ≤ 2 lines, and group C: 11 eyes with no change or change within 1 line. RESULTS: The HOAs of the posterior surface in group B were significantly greater than those of group A (P=0.028), whereas there were no significant differences in the anterior surface and total corneal HOAs between groups A and B (P=0.12 and 0.08). There were no significant differences in the anterior and posterior surface as well as total cornea HOAs between initial DSAEK and repeat DSAEK in group C (P=0.87, 0.65, and 0.42). The postoperative BCVA had a significant correlation with the HOAs of the anterior and posterior surfaces as well as the total cornea (R=0.40, 0.46, and 0.53; P=0.01, 0.002, and 0.001). CONCLUSIONS: Posterior corneal HOAs can have a negative influence on the visual acuity after endothelial keratoplasty.

Association of Epithelial Atypia With Recurrence After Surgical Excision in Conjunctival Papilloma.

PURPOSE: To investigate the association between recurrence of conjunctival papillomas and presence of atypical epithelial changes in patients undergoing surgical excision for conjunctival papilloma. METHODS: We retrospectively reviewed 1,195 ophthalmic pathology specimens from 2004 to 2014 at Ichikawa General Hospital. Pathologic specimens of 5 patients with a final diagnosis of "conjunctival papilloma" were stained with hematoxylin-eosin, Ki 67, p53, human papillomavirus (HPV) 16 and 18 antibodies. RESULTS: Of 1,195 patients, 5 patients (4 men, 1 woman; age range: 27∼57 years, mean age: 38.4 years) had a diagnosis of conjunctival papilloma, which constituted to 0.42% of the pathologic diagnosis made for the ophthalmology specimens. All specimens displayed multiple fronds of thickened conjunctival epithelium that enclosed cores of vascularized connective tissues. Three patients with recurrence after surgical excision demonstrated moderate to severe epithelial atypia, who also showed higher staining with Ki67 and p53 compared with patients with no recurrence. HPV16 and 18 antibodies staining did not appear to relate to recurrences. CONCLUSIONS: Conjunctival papillomas with higher positive staining for Ki67 and p53 seem to have a higher risk of recurrence even after complete surgical excision and necessitate careful follow-up.

Topographic characteristics after Descemet's membrane endothelial keratoplasty and Descemet's stripping automated endothelial keratoplasty.

PURPOSE: To investigate the topographic characteristics of the posterior corneal surface after Descemet's endothelial membrane keratoplasty (DMEK) and Descemet's stripping automated endothelial keratoplasty (DSAEK) and their effects on postoperative visual acuity. METHODS: Nineteen eyes of 19 patients after DMEK, 23 eyes of 23 patients after DSAEK, and 18 eyes of 18 control subjects were retrospectively analyzed. Best spectacle-corrected visual acuity (BSCVA), aberration factors (higher-order aberrations [HOAs], spherical aberrations [SAs], and coma aberrations [Comas] at 6.0 mm) were evaluated preoperatively and at 1, 3, and 6 months postoperatively. The posterior refractive pattern of the topography map was classified into 5 grades (0-5) (posterior color grade) using anterior segment optical coherence tomography. Correlations between BSCVA and some factors (abbreviation factors, posterior color grade) were analyzed. RESULTS: BSCVA was significantly better after DMEK than after DSAEK (P < 0.001). Posterior HOAs, SAs, and Comas after each type of endothelial keratoplasty were significantly greater compared to control (P < 0.01). Posterior HOAs, total/anterior/posterior SAs, and posterior color grade were significantly lower in the DMEK group than in the DSAEK group at 3 months (P < 0.024 [posterior HOAs], P = 0.047 [total SA], P < 0.001 [anterior SAs], P = 0.021 [posterior SAs], and P < 0.001 [posterior color grade]) and 6 months postoperatively (P = 0.034 [posterior HOAs], P < 0.001 [total SAs], P < 0.001 [anterior SAs], P = 0.013 [posterior SAs], and P = 0.004 [posterior color grade]). BSCVA was significantly correlated with HOAs, SAs, and posterior color grade (P < 0.001 for all except anterior HOAs [P = 0.004]). CONCLUSIONS: High posterior color grades were associated with larger aberration factors and had a negative effect on visual function after endothelial keratoplasty. Rapid improvement of visual function after DMEK may be attributed to less change at the posterior surface.

The characterization of human oral mucosal fibroblasts and their use as feeder cells in cultivated epithelial sheets.

AIM: To characterize human oral mucosa middle interstitial tissue fibroblasts (hOMFs) and their application in the cultivation of epithelial sheets. METHODOLOGY: hOMFs were cultured with methylcellulose to form cell clusters. hOMFs amplified in adhesive culture were analyzed by flow cytometry, and were found to differentiate into multiple cell types suitable for the cultivation of human corneal epithelial sheets. hOMFs were expanded from clusters to analyze CD56 and PDGFRα expression. RESULTS: These cells showed similar differentiation patterns as keratocytes, and similar expression patterns as mesenchymal and neural cells. Furthermore, we established human corneal epithelial sheets using hOMFs. CONCLUSION: hOMFs may be of neural crest origin and possess multipotent differentiation capacity, and are suitable for use as an autologous cell source for corneal regeneration.

Elevated Aqueous Cytokine Levels in Eyes With Ocular Surface Diseases.

PURPOSE: To evaluate cytokine and protein levels in the aqueous humor (AqH) of eyes with ocular surface diseases. DESIGN: Prospective consecutive case series. METHODS: This study includes 14 patients (aged 62.4 ± 13.7 years) with chronic-phase ocular surface diseases (4 with ocular cicatricial pemphigoid, 5 with chemical burns, 2 with a thermal burn, 2 with Stevens-Johnson syndrome, and 1 with exposure keratitis), 14 matched patients without ocular surface disease (controls with corneal scar), and 30 patients who underwent cataract surgery (healthy controls). AqH samples were collected at the beginning of surgery. AqH levels of cytokines (interleukin [IL]-1α, IL-1ß, IL-4, IL-6, IL-8, IL-10, IL-12p70, IL-13, IL-17A, monocyte chemotactic protein [MCP]-1, interferon [IFN]-α, IFN-γ, macrophage inflammatory protein [MIP]-1α, MIP-1ß, P-selectin, E-selectin, soluble-intercellular adhesion molecule [s-ICAM]-1, tumor necrosis factor [TNF]-α, granulocyte-macrophage colony-stimulating factor [GM-CSF], IFN-γ-induced protein [IP]-10) were measured using multiplex beads immunoassays. RESULTS: The levels of IL-6, IL-10, IL-17A, GM-CSF, E-selectin, P-selectin, and s-ICAM in AqH were significantly elevated in eyes with ocular surface diseases (in pg/mL: 1696 ± 804, 4.0 ± 1.0, 24.3 ± 9.8, 26.0 ± 18.3, 5150 ± 1232, 13122 ± 7219, and 7914 ± 2813, respectively), compared to healthy controls (IL-6: 6.36 ± 0.94, P = .001; IL-10: 1.68 ± 0.04, P = .0006; IL-17A: 3.7 ± 0.2, P = .008; GM-CSF: 2.7 ± 0.3, P = .007; E-selectin: 2093 ± 37, P = .0001; P-selectin: 3658 ± 137, P = .0001; sICAM-1: 1397 ± 119, P = .008). The levels of IL-6, IL-17A, E-selectin, and P-selectin in AqH were significantly higher in eyes with ocular surface diseases compared to those with corneal scar (IL-6: 44.1 ± 15.0, P = .0077; IL-17A: 4.1 ± 0.7, P = .034; E-selectin: 2439 ± 302, P = .039; and P-selectin: 5673 ± 1553, P = .017). CONCLUSIONS: Multiple AqH cytokine levels were elevated in chronic ocular surface diseases.

Association between corneal endothelial cell densities and elevated cytokine levels in the aqueous humor.

Annual reduction rate of corneal endothelial cell density (ECD) varies among etiologies, however, the cause of chronic endothelial cell loss is still unknown. We recently reported the elevation of inflammatory cytokines in the aqueous humor (AqH) in eyes with bullous keratopathy and low ECD. To evaluate the association between ECD and aqueous cytokine levels, we collected a total of 157 AqH samples prospectively. The AqH levels of cytokines were measured and multivariate analyses were conducted to find the correlation between ECD, aqueous cytokine levels and clinical factors, such as number of previous intraocular surgeries and protein concentration in AqH. As a result, ECD was negatively correlated with specific cytokine levels, including IL-1α, IL-4, IL-13, MIP-1ß, TNF-α and E-selectin (all P < 0.05). The aqueous cytokine levels showed different correlations with these clinical factors; the number of previous intraocular surgeries was associated with all cytokines except MIP-1α. The AqH protein concentration and the status of intraocular lens showed similar patterns of elevation of IL-1α, IL-4, IL-6, IL-8, IL-10, IL-13, IL-17A, MIP-1ß, MCP-1, E-selectin, P-selectin and sICAM-1. In conclusion, elevation of AqH cytokine levels was associated with reduced ECDs. AqH cytokine levels showed significant correlations with clinical factors associated with low ECDs.

A Novel Entity of Corneal Diseases with Irregular Posterior Corneal Surfaces: Concept and Clinical Relevance.

Various corneal diseases, such as hereditary corneal dystrophies, corneal infection, and bullous keratopathy, cause corneal opacity, scarring, and edema, leading to severely decreased visual acuity and loss of vision. These diseases were regarded as corneal opacity diseases, and the decreased visual acuity was considered to be predominantly caused by corneal opacity. The influence of corneal irregular astigmatism on vision has been poorly understood to date, mainly because accurate quantification of irregular astigmatism has been technically challenging. We have performed detailed analyses of the corneal higher-order aberrations (HOAs) of the anterior and posterior surfaces and total cornea in corneal diseases, using an anterior segment imaging system combined with a ray-tracing method. Subsequently, we conducted correlation analyses between corneal HOAs and visual acuities and characterized the typical HOA patterns in the corneal diseases. Our recent studies demonstrated that corneal HOAs directly degrade visual acuity in eyes with mild-to-moderate corneal opacities, such as corneal dystrophies, corneal scarring, and bullous keratopathy. The findings also suggested that correction of corneal HOAs using rigid gas-permeable contact lenses is effective in eyes with a smooth posterior surface and useful in certain patients with corneal scarring to some extent. Our data will be useful for decision making regarding surgical interventions, based on the amount of corneal HOAs. Our results further indicate the clinical relevance of irregular astigmatism in the posterior surfaces in assessing the visual function of eyes with various corneal diseases.

Corneal Higher-order Aberrations and Visual Improvement Following Corneal Transplantation in Treating Herpes Simplex Keratitis.

PURPOSE: To examine corneal higher-order aberrations (HOAs) and visual improvement following corneal transplantation in treating corneal scar caused by herpes simplex keratitis (HSK). DESIGN: Retrospective consecutive case series. METHODS: This study included a total of 52 eyes: 18 eyes of normal subjects, and 34 eyes of consecutive patients with corneal scar owing to HSK who underwent penetrating keratoplasty (PKP, 17 eyes) or deep anterior lamellar keratoplasty (DALK, 17 eyes). HOAs of the anterior, posterior surfaces and the total cornea were analyzed by anterior segment optical coherence tomography. The correlations between corneal HOAs and visual improvement were also analyzed. RESULTS: Mean logarithm of the minimal angle of resolution (logMAR) visual acuity significantly improved from 1.40 ± 0.70 to 0.46 ± 0.45 after corneal transplantation (P < .0001). Mean corneal HOAs of the anterior surface significantly decreased after corneal transplantation (PKP: from 1.16 ± 0.59 µm to 0.58 ± 0.35 µm, P = .035, DALK: from 0.94 ± 0.57 µm to 0.37 ± 0.18 µm, P = .004). Visual acuity following corneal transplantation was correlated with the corneal HOAs at 12 months (r = 0.53, P = .01). Visual improvement at 3, 6, and 12 months was positively correlated with preoperative HOAs of the total cornea and posterior surface (all P < .01). CONCLUSIONS: Preoperative corneal HOAs were associated with the visual improvement in treating corneal scar caused by HSK. Thus, the preoperative assessment of corneal HOAs, especially of the posterior surface, is important in the decision to perform corneal transplantation in eyes with HSK.