Long-term outcomes of glued (sutureless) amniotic membrane transplantation in acute Stevens-Johnson syndrome/toxic epidermal necrolysis: a comparative study.

PURPOSE: To compare the effectiveness and efficiency of a glued (sutureless) technique for amniotic membrane transplantation (AMT) with a traditional sutured one in the setting of acute Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN). METHODS: This retrospective cohort study evaluated all patients diagnosed with SJS/TEN between 2008 and 2020 within our hospital network who received AMT in the acute phase according to our protocol and had at least one ophthalmic follow-up in the chronic phase. Primary outcomes included best-corrected visual acuity (BCVA) at the most recent visit, presence of a severe ocular complication (SOC) via predefined criteria, time to procedure and duration of procedure. Random effects model analysis was used to evaluate the impact of potential covariates on outcome measures. RESULTS: A total of 23 patients (45 eyes) were included: 14 patients (27 eyes) in the AMT suture group and 9 patients (18 eyes) in the AMT glue group. There was no difference between the two groups in BCVA at the most recent visit (p=0.5112) or development of a SOC (p=1.000). The glue method was shorter in duration than the suture method (p<0.001). Random effects model additionally indicated that there was no difference in BCVA at most recent follow-up between patients who had received glued versus sutured AMT (p=0.1460). CONCLUSIONS: Our glued technique for AMT is as effective as our sutured technique in stabilising the ocular surface and mitigating chronic ocular complications in SJS/TEN. The glued technique is also shorter in duration and performed more expediently than the sutured technique.

Comparative analysis of long-term results of three epithelial cell transplantation procedures for treating limbal stem cell deficiency.

This study compared the long-term outcome of different epithelial transplantation techniques to treat limbal stem cell deficiency (LSCD). We conducted a retrospective 15-year comparative systematic cohort study of patients with LSCD who underwent either cultivated limbal epithelial transplantation (CLET), simple limbal epithelial transplantation (SLET), or cultivated oral mucosal epithelial transplantation (COMET). We reviewed the demographic data, etiology, LSCD severity, best-corrected visual acuity, surgical outcomes, and complications. A total of 103 eyes of 94 patients (mean age, 45.0 ± 16.4 years) with LSCD were enrolled. The most common cause of LSCD was chemical injury (42.7 %). The median follow-up time was 75 months. The success rates of CLET, SLET, and COMET were 45.5 %, 77.8 %, and 57.8 %, respectively. The 7-year survival rates after CLET, SLET, and COMET were 50.0 %, 72.2 %, and 53.2 %, respectively. Steven-Johnson syndrome (SJS) had a significantly lower survival rate than other causes (p < 0.001), but SLET had a significantly higher survival rate than CLET (p = 0.018) and COMET (p = 0.047). Visual improvement of more than four Snellen lines was achieved in 53.1 % of successful cases and 28.2 % of failed cases. SJS, Schirmer I test <5 mm, and the presence of postoperative recurrent epithelial defects were significant risk factors for a failed surgery. All epithelial transplantation techniques had favorable long-term surgical outcomes. More than half of the patients achieved a stable ocular surface and visual acuity improvement up to 7 years postoperatively. SLET tends to have a better surgical outcome than CLET and COMET, especially in patients with SJS.

Comparison of epitheliotrophic factors in platelet-rich plasma versus autologous serum and their treatment efficacy in dry eye disease.

Current treatment of severe dry eye disease (DED) includes blood-derived eye drops, such as autologous serum (AS), which lubricate the eyes and provide factors that improve ocular surface and aid in wound healing. Recent studies indicated that platelet-rich plasma (PRP) was also effective. This study aims to compare the concentration and stability of epitheliotrophic factors in AS and PRP and their efficacy in DED patients. Epitheliotrophic factors of interest are epidermal growth factor (EGF), fibronectin, platelet-derived growth factor-AB (PDGF-AB), and transforming growth factor-beta1 (TGF-ß1). We determined that all epitheliotrophic factors were present in AS and PRP at baseline and did not decrease in concentrations in all storage conditions (4 °C for 1 week and at - 20 °C for 1 and 3 months). However, differences in concentrations in AS and PRP were observed. PRP was also shown not to be inferior to AS in terms of efficacy in DED treatment in a prospective randomized control trial which evaluated ocular surface disease index, dry eye questionnaire, ocular surface staining, tear breakup time, and Schirmer test at baseline and at 1-month follow-up. Therefore, with its shorter preparation time, PRP could be considered as an alternative to AS for the treatment of DED.

Provocation of dry eye disease symptoms during COVID-19 lockdown.

To assess the impact of COVID-19 lockdown measures on dry-eye symptoms in a community-based population, a cross-sectional study was conducted during the first wave of the COVID-19 outbreak in Thailand. An online survey was distributed via social media between June and July 2020. The questionnaire elicited information on demographics, dry-eye symptoms, use of visual display terminals, and mental health status. There were 535 respondents. Thirty-seven percent reported having been diagnosed with dry-eye disease (DED). During the lockdown, the mean dry-eye symptom score (DESS) of overall participants dropped significantly from 81.6 ± 15.9 to 79.8 ± 17.4 (P < 0.001). The mean, daily, visual display terminal (VDT) usage increased from 10.55 ± 5.16 to 13.08 ± 5.65 h (P < 0.001). A negative correlation between age and VDT usage was observed in both the normal and lockdown situations. One-quarter of all participants had an abnormal mental health status. The female gender (OR 1.86; 95% CI 1.14-3.04) and increased VDT usage during the lockdown (OR 5.68; 95% CI 3.49-9.23) were independently associated with worsening dry-eye symptoms. The lockdown measures abruptly altered the behaviors and lifestyles of the overall population. Excessive exposure to VDTs were associated with deteriorated dry-eye symptoms, and it possibly contributed to the increased DED incidence in the surveyed population.

Efficacy and outcome of simple limbal epithelial transplantation for limbal stem cell deficiency verified by epithelial phenotypes integrated with clinical evaluation.

PURPOSE: To evaluate the efficacy and outcome of simple limbal epithelial transplantation (SLET) for limbal stem cell deficiency (LSCD) using epithelial phenotype detection integrated with clinical manifestation. METHODS: This prospective multicenter study included patients with LSCD who underwent autologous SLET (autoSLET) and living-related allogenic SLET (Lr-alloSLET). All patients were assessed by slit-lamp biomicroscopy, in vivo confocal microscopy (IVCM), and impression cytology with immunofluorescence staining (ICIF) before and after surgery. The criteria for success were the presence of a clinically non-conjunctivalized cornea and corneal epithelium detected by IVCM or ICIF. Otherwise, the case would be considered a failure. Visual improvement and risk factors for SLET failure were analyzed. RESULTS: A total of 28 eyes of 26 patients (11 autoSLET and 17 Lr-alloSLET) were included. The median age was 53 years (range, 35-63), and the follow-up time was 29.5 months (range, 17.5-39.8). The overall survival rate was 89.3% at 2 years and 75.6% at 3 years with no difference between autoSLET and Lr-alloSLET (p = 0.24). Seven eyes subsequently underwent penetrating keratoplasty. Immunohistochemistry analysis showed that all corneal buttons had corneal epithelium and limbal stem cell markers. Visual improvement was achieved in both SLET groups (p < 0.001). Failed SLET developed between 5 and 32 months postoperatively. However, absolute risk factors for SLET failure were unidentified. CONCLUSION: The efficacy of autoSLET and Lr-alloSLET for LSCD was excellent. Limbal explants can regenerate and restore the corneal surface while maintaining the characteristics of limbal stem cells as shown by epithelial phenotype detection and immunohistochemistry integrated with clinical evaluation.

Long-term Outcomes of Boston Type I Keratoprosthesis, and Efficacy of Amphotericin B and Povidone-Iodine in Infection Prophylaxis.

PURPOSE: To evaluate the long-term outcomes, anatomic retention, and complications of Boston type I keratoprosthesis (KPro). DESIGN: Retrospective, interventional case series METHODS: A retrospective chart review of implantations performed January 2008-December 2017 was conducted. Risk factors for anatomical retention and functional success were analyzed. The incidences of infections with and without antimicrobial medications were compared. RESULTS: Twenty-seven eyes of 26 patients were recruited. The most common indication for KPro surgery was failed penetrating keratoplasties (22 eyes, 81.5%). All patients had preoperative best-corrected visual acuity (BCVA) worse than 3/60. Over the mean follow-up of 83.4 ± 28.4 months, 15 eyes (55.6%) demonstrated improved BCVA. The anatomical retention rate was 88.9%, and the functional success rate was 44.4% (retained KPro with BCVA ≥ 3/60). Eyes with ocular surface disease (OSD) had significantly more complications than those without OSD. The most common complications were retroprosthetic membrane formation (15 eyes, 55.6%) and infection (13 eyes, 48.1%). Infectious keratitis was primarily caused by gram-positive bacteria, whereas endophthalmitis was chiefly caused by fungal infection. The infection incidence was significantly lower in eyes using topical 0.1% amphotericin B and 5% povidone iodine (P = .008 and .021, respectively). CONCLUSIONS: With its good retention rate and visual outcomes, Boston type I KPro could be an alternative treatment for patients with conventional penetrating keratoplasty failure, especially with appropriate patient selection and complication prevention. Standard prophylactic antibiotics with the addition of topical 0.1% amphotericin B and 5% povidone iodine might be optional effective regimens for infection prevention, especially in tropical countries.

Successful Ocular Surface Reconstruction in Complete Ankyloblepharon With the Simple Oral Mucosal Epithelial Transplantation Technique: A Case Report.

PURPOSE: To report an outcome of a patient with complete ankyloblepharon successfully managed with simple oral mucosal epithelial transplantation (SOMET). METHODS: A 55-year-old woman presented with complete adhesion of both lids to the ocular surface as a complication from Stevens-Johnson syndrome. We performed 2-staged reconstructive surgeries: the first stage was to perform ankyloblepharon lysis and surface reconstruction with a mucosal graft on the palpebral area and an amniotic membrane on the bulbar area, and the second stage was to reconstruct the bulbar area with a transplantation of small pieces of oral mucosa (SOMET technique). Postoperatively, the patient was evaluated for ocular surface stability, recurrent symblepharon, in vivo confocal microscopy, and impression cytology with immunofluorescence staining. RESULTS: Complete epithelialization of cornea-like epithelium was observed within 6 weeks after SOMET was performed. The ocular surface was stable over 1 year. Both fornices remained deep. In vivo confocal microscopy showed cornea-like epithelium mixed with conjunctival epithelium, as confirmed with immunofluorescence staining, which revealed cytokeratin 3, cytokeratin 7, and cytokeratin 12 positivity. CONCLUSIONS: SOMET is a simple modified technique using minimal oral mucosal tissue to regenerate epithelialization for complicated ocular surface reconstruction such as a complete ankyloblepharon repair. Although there was evidence of conjunctival invasion, stable ocular surface and deep fornices can be achieved for further visual rehabilitative procedure.

Characterization of limbal explant sites: Optimization of stem cell outgrowth in in vitro culture.

Simple limbal epithelial transplantation (SLET) and cultivated limbal epithelial transplantation (CLET) are proven techniques for treating limbal stem cell deficiency (LSCD). However, the precise regions that are most suitable for preparing explants for transplantation have not been identified conclusively. Accordingly, this in vitro study aimed at determining ideal sites to be selected for tissue harvest for limbal stem cell culture and transplantation. We evaluated cell outgrowth potential and the expression of stem cell markers in cultures from 48 limbal explants from five cadaveric donors. The limbal explants were generated from the three specific sites: Lcor (located innermost and adjacent to the cornea), Lm (middle limbus), and Lconj (located outermost adjacent to the conjunctiva). We found that explants from the Lconj and Lm sites exhibited higher growth potential than those from the Lcor site. Transcript encoding the stem cell marker and p63 isoform, ΔNp63, was detected in cells from Lm and Lconj explants; expression levels were slightly, though significantly (p-value < 0.05), higher in Lm than in Lconj, although expression of ΔNp63α protein was similar in cells from all explants. Differential expression of ATP-Binding Cassette Subfamily G Member 2 (ABCG2) did not reach statistical significance. Immunohistochemistry by indirect immunofluorescence analysis of limbus tissue revealed that the basal layer in explant tissue from Lconj and Lm contained markedly more stem cells than found in Lcor explant tissue; these findings correlate with a higher capacity for growth. Collectively, our findings suggest that explants from the Lconj and Lm sites should be selected for limbal cell expansion for both CLET and SLET procedures. These new insights may guide surgeons toward specific limbal sites that are most suitable for stem cell culture and transplantation and may ultimately improve treatment outcomes in the patients with LSCD.

Keratoconus in Patients with Macular Stromal Dystrophy.

OBJECTIVE: To show the association between keratoconus and macular dystrophy. MATERIAL AND METHOD: All patients with macular dystrophy and associated clinical findings leading to a diagnosis of keratoconus by corneal topography were retrospectively reviewed during a 10-year period. Uncorrected and best-corrected visual acuity, automated refraction, manifest refraction, corneal thickness, and corneal curvature by corneal topography were evaluated RESULTS: Three patients with macular dystrophy exhibiting decreased vision, multifocal white dense deposits, and haze surrounding the deposits in the corneal stroma were evaluated. All had a steep corneal curvature of >47 diopters and a thin cornea consistent with keratoconus. Penetrating keratoplasty was performed in one patient with severely decreased vision. Macular dystrophy was diagnosed based on an Alcian blue-stained pathological specimen. CONCLUSION: Keratoconus may develop as a result of changes associated with macular dystrophy. Therefore, patients with severely decreased vision should be evaluated for keratoconus to ensure proper management.

Prevalence of dry eye syndrome and Sjogren's syndrome in patients with rheumatoid arthritis.

BACKGROUND: Rheumatoid arthritis has manifestations in various organs including ophthalmic involvement. The present study evaluates prevalence of dry eye and secondary Sjogren's syndrome using salivary scintigraphy which has not been used in previous reports. OBJECTIVE: To evaluate the prevalence of secondary Sjogren's syndrome in patients with rheumatoid arthritis, including clinical characteristics and dry eye, compared with non-Sjogren's syndrome. DESIGN: Descriptive cross sectional study MATERIAL AND METHOD: Sixty-one patients with rheumatoid arthritis were recruited at Siriraj Hospital during March 2009-September 2010 and filled in the questionnaires about dry eye for Ocular Surface Disease Index (OSDI) with a history taking of associated diseases, medications, duration of symptoms of dry eyes and dry mouth. The Schirmer I test without anesthesia, tear break-up time, rose bengal staining score, severity of keratitis and salivary scintigraphy were measured and analyzed. RESULTS: Prevalence of secondary Sjogren's syndrome and dry eye were 22.2% (95% CI 15.4 to 30.9) and 46.7% (95% CI 38.0 to 55.6), respectively. Dry eye interpreted from OSDI, Schirmer 1 test, tear break-up time and rose bengal staining was 16.4%, 46.7%, 82% and 3.3% respectively. Fifty-two percent of patients had a history of dry eye and dry mouth with mean duration 27.4 and 29.8 months, respectively. Superficial punctate keratitis and abnormal salivary scintigraphy were found in 58.2% and 77.8%. Duration of rheumatoid arthritis, erythrocyte sedimentation rate were not correlated with secondary Sjogren's syndrome. Dry eye from OSDI with secondary Sjogren's syndrome (33.3%) compared with non-Sjogren's syndrome (9.5%) was significant difference (p = 0.008). Adjusted odds ratio for secondary Sjogren's syndrome in OSDIL score > 25 was 13.8 (95% CI 2.6 to 73.8, p = 0.002) compared to OSDI score < 25. CONCLUSION: Awareness and detection of dry eye syndrome and secondary Sjogren's syndrome in rheumatoid arthritis was crucial for evaluation of their severity and proper management.