Severe ocular complications of SJS/TEN and associations among pre-onset, acute, and chronic factors: a report from the international ophthalmology collaborative group.

We formed an international research collaboration that included Japan, South Korea, Brazil, Thailand, Taiwan, the UK, and the US (682 patients from 13 hospitals between 2005 and 2020), to better evaluate the role of race, ethnicity, and other risk factors in the pathophysiology of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). Ophthalmologists often see SJS/TEN patients with severe ocular complications (SOC; frequency 50% SJS/TEN patients) when the patients are referred to them in the chronic stage after the acute stage has passed. Global data were collected using a Clinical Report Form, capturing pre-onset factors, as well as acute and chronic ocular findings. Key conclusions of this retrospective observational cohort study were as follows: (1) Ingestion of cold medications [acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs)] was significantly and positively correlated with trichiasis, symblepharon, and/or conjunctivalization of the cornea in the chronic stage; (2) common cold symptoms prior to onset of SJS/TEN were significantly and positively correlated with acute conjunctivitis and ocular surface erosions in the acute stage and with trichiasis and symblepharon and/or conjunctivalization of the cornea in the chronic stage; (3) patients with SJS/TEN who presented with SOC tended to be female; (4) patients less than 30 years of age are more likely to develop SOC in the acute and chronic stages of SJS/TEN; (5) patients with acute severe conjunctivitis with ocular surface erosion and pseudomembrane formation in the acute stage are more likely to develop ocular sequelae in the chronic stage; and (6) onychopathy in the acute stage was positively correlated with ocular sequelae in the chronic stage. Our findings show that the ingestion of cold medications, common cold symptoms prior to the onset of SJS/TEN, and a young age might strongly contribute to developing the SOC of SJS/TEN.

A Retrospective Analysis of Tear Film and Blink Parameters in Patients With Ocular Surface Disease.

OBJECTIVES: We had two objectives: (1) to investigate differences in tear film and blink parameters in patients with six ocular surface diseases (OSD): ocular graft versus host disease (oGVHD), Stevens-Johnson syndrome (SJS), lax eyelid syndrome, meibomian gland dysfunction (MGD), obstructive sleep apnea, and dry eye disease; and (2) to characterize the relationships between lipid layer thickness (LLT), meiboscore, Schirmer I test, and three blink parameters: partial blink rate (PBR), interblink interval (IBI), and interpalpebral fissure height (IPFH) in this group of patients. METHODS: This is a single-site retrospective analysis of 228 patients (456 eyes) with six different primary OSD at Loyola University Medical Center between January 2018 and July 2020. Objective parameters included: LLT, IBI, PBR, IPFH, Pult meiboscore, and Schirmer I score. Linear mixed effects models were used to analyze the relationships between these parameters. RESULTS: The meiboscore was highest in patients with SJS compared with the other five groups. There was significant variability in IPFH across different groups, with patients with oGVHD having the smallest height. An increase in IPFH was associated with increases in IBI, PBR, and Schirmer score. Patients with no partial blinks demonstrated a statistically significant higher IBI than patients who showed 1%-50% partial blinks. Finally, no statistically significant relationship was found between the following: (1) meiboscore and LLT, (2) OSDI and IPFH, (3) Schirmer score and IBI, or (4) LLT and IBI. CONCLUSIONS: There were fewer than anticipated differences in objective tear film and blink parameters between patients with six different OSD. A statistically significant association was found between IPFH and Schirmer score and IPFH and IBI, representing new findings in tear film research. Further investigation of the relationship between IPFH and IBI is needed.

The Microbiome, Ocular Surface, and Corneal Disorders.

The ocular surface microbiome is an emerging field of study that seeks to understand how the community of microorganisms found on the ocular surface may help maintain homeostasis or can potentially lead to disease and dysbiosis. Initial questions include whether the organisms detected on the ocular surface inhabit that ecological niche and, if so, whether there exists a core microbiome found in most or all healthy eyes. Many questions have emerged around whether novel organisms and/or a redistribution of organisms play a role in disease pathogenesis, response to therapies, or convalescence. Although there is much enthusiasm about this topic, the ocular surface microbiome is a new field with many technical challenges. These challenges are discussed in this review as well as a need for standardization to adequately compare studies and advance the field. In addition, this review summarizes the current research on the microbiome of various ocular surface diseases and how these findings may impact treatments and clinical decision-making.

Hardware complications and reoperations following precontoured plate fixation of the olecranon: a population-based study.

BACKGROUND: Several fixation techniques have been described to treat acute olecranon fractures. Plate fixation is often used because of its superior mechanical properties. The reported rates of reoperation after olecranon plate fixation have been quite heterogeneous. The purpose of this study was to establish an updated reoperation rate based on modern precontoured plate constructs. METHODS: This retrospective cohort study used population-level administrative data to identify all surgically treated adult patients with olecranon fractures at 4 hospitals in Edmonton, AB, Canada, between 2010 and 2015. Radiographic review was conducted to identify patients who underwent precontoured olecranon plate fixation. Fracture characteristics including Mayo fracture classification and other concomitant upper-extremity injuries were identified. Chart reviews were performed to determine patient characteristics and patients who required reoperation. The primary reason for and type of reoperation were determined. RESULTS: Six hundred patients were surgically treated for olecranon fractures. Precontoured plate fixation was used in 321 patients. The average age of included patients was 56 years (standard deviation [SD], 19.4 years), and there were 173 female patients (53.9%). Reoperation was required in 90 patients (28%). For 50 patients, implant-related irritation was the primary reason for reoperation, representing 55.6% of the patients who underwent reoperation (50 of 90) and 15.6% of the total cohort (50 of 321). Other reasons for reoperation included hardware failure in 17 patients (5.3%), infection in 9 (2.8%), and contracture in 9 (2.8%). Patients who required reoperation were significantly younger (52.9 years [SD, 18.1 years] vs. 57.7 years [SD, 19.4 years]; P = .048) and had significantly higher rates of type III olecranon fractures (17.8% [16 of 90] vs. 8.2% [19 of 231]; P = .04) and Monteggia fractures (13.3% [12 of 90] vs. 4.8% [11 of 231]; P = .008). A multivariate logistic regression model also demonstrated increased odds ratios (ORs) for overall reoperation in patients with Monteggia fractures (OR, 2.99 [95% confidence interval, 1.25-7.17]; P = .014) and for reoperation due to implant-related irritation in younger patients (OR, 0.98 [95% confidence interval, 0.96-0.996]; P = .018). No discerning factors were identified for the 50 patients who underwent hardware removal for implant-related irritation compared with the whole reoperation group (n = 90). CONCLUSION: This study found that patients with olecranon fractures treated with precontoured plates experienced a hardware removal rate of 15.6% for implant-related irritation. Patients who sustained more complex fractures, such as Monteggia injuries, demonstrated higher rates of reoperation. Increasing age may be associated with lower rates of reoperation. In patients who required reoperation, there were no identifiable radiographic or clinical characteristics that were associated with implant-related irritation as their primary reason for reoperation.

A novel telemedicine technique for evaluation of ocular exam findings via smartphone images.

In this study, we compared the assessment of remote smartphone photographs to in-office exams in the diagnosis of two groups of external eye diseases, red-eye pathology and post-operative eyelid surgery complications. Participants were examined and received an in-office diagnosis by either a corneal or oculoplastic specialist. After viewing an educational video on smartphone photography, the patient's companion then took a series of standardized photographs. Two additional corresponding specialists then made a separate diagnosis via the interpretation of only smartphone images and the patient's history. 'Remote' and in-office diagnoses were compared using a kappa test for agreement. The remote and in-office diagnoses were in agreement for 27 of 28 eyes, representing a chance-corrected Kappa agreement rate of 93% (95% confidence interval: 79-99%). Among the 16 red eyes, the diagnoses were in agreement for 15 of 16 red eyes, representing a chance-corrected Kappa agreement rate of 92% (95% confidence interval: 77-99%). Among the 12 eyes with post-operative eyelid surgery complications, the diagnoses were in perfect agreement. Our results suggest that the diagnosis of 1) red-eye pathology and 2) post-operative eyelid surgery complications based on smartphone images may be comparable to in-office exams.

Review of culprit drugs associated with patients admitted to the burn unit with the diagnosis of Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis Syndrome.

PURPOSE: Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis Syndrome (TENS) are severe and potentially lethal adverse drug reactions characterized by acute inflammation of the skin, mucous membranes, and ocular surface that typically occurs within weeks of a culprit drug ingestion. The purpose of this study is to report a retrospective trend analysis of SJS spectrum diagnoses and associated culprit drugs in patients admitted to the Loyola University Medical Center (LUMC) Burn Unit, the major referral center in the Chicagoland region for patients with SJS disease spectrum. METHODS: The electronic medical records (EMR) of 163 patients with a diagnosis of SJS/TENS admitted to the LUMC Burn Unit from 2000 to 2019 were reviewed. Clinical data in addition to the well-established algorithm of drug causality for epidermal necrolysis (ALDEN) allowed us to identify the single most probable culprit drug in 131 cases. RESULTS: From 2000 to 2019, the most common spectrum classification was TENS (48.1%), followed by SJS (33.6%) and SJS-TEN Overlap Syndrome (18.3%). Anticonvulsants were found to be the most probable culprit class in 30% of cases followed by Trimethoprim-Sulfamethoxazole in 19% of cases. Beta-lactams were the most probable culprit class in 11% of cases while NSAIDs and allopurinol were each the most probable culprit class/drug in 8.4% of cases. CONCLUSIONS: This is one of the largest single center series of SJS/TENS cases in the United States. Further study into culprit drug distribution by region as well as continuous monitoring of trends is crucial in order to advise prescribing practices.

Corneal perforation in ocular graft-versus-host disease.

PURPOSE: Corneal perforation is a rare, vision-threatening complication of ocular graft-versus-host disease (GVHD) and is not well understood. Our objective was to examine the clinical disease course and histopathologic correlation in patients who progressed to this outcome. METHODS: This study is a retrospective case series from four academic centers in the United States. All patients received a hematopoietic stem cell transplant (HSCT) prior to developing ocular GVHD. Variables of interest included patient demographics, time interval between HSCT and ocular events, visual acuity throughout clinical course, corticosteroid and infection prophylaxis regimens at time of corneal perforation, medical/surgical interventions, and histopathology. RESULTS: Fourteen eyes from 14 patients were analyzed. Most patients were male (86%) and Caucasian (86%), and average age at time of hematopoietic stem cell transplant was 47 years. The mean interval between hematopoietic stem cell transplant and diagnosis of ocular graft-versus-host disease was 9.5 months, and between hematopoietic stem cell transplant and corneal perforation was 37 months. Initial best-corrected visual acuity was 20/40 or better in 9 eyes, and all eyes had moderate or poor visual outcomes despite aggressive management, including corneal gluing in all patients followed by keratoplasty in 8 patients. The mean follow-up after perforation was 34 months (range 2-140 months). Oral prednisone was used prior to perforation in 11 patients (79%). On histopathology, representative specimens in the acute phase demonstrated ulcerative keratitis with perforation but minimal inflammatory cells and no microorganisms, consistent with sterile corneal "melt" in the setting of immunosuppression; and in the healed phase, filling in of the perforation site with fibrous scar. CONCLUSIONS: In these patients, an extended time interval was identified between the diagnosis of ocular graft-versus-host disease and corneal perforation. This represents a critical window to potentially prevent this devastating outcome. Further study is required to identify those patients at greatest risk as well as to optimize prevention strategies.

Acute and Chronic Management of Ocular Disease in Stevens Johnson Syndrome/Toxic Epidermal Necrolysis in the USA.

Stevens Johnson syndrome and toxic epidermal necrolysis are on a spectrum of a severe, immune-mediated, mucocutaneous disease. Ocular involvement occurs in the vast majority of cases and severe involvement can lead to corneal blindness. Treatment in the acute phase is imperative in mitigating the severity of chronic disease. Advances in acute treatment such as amniotic membrane transplantation have shown to significantly reduce the severity of chronic disease. However, AMT is not a panacea and severe chronic ocular disease can and does still occur even with aggressive acute treatment. Management of chronic disease is equally critical as timely intervention can prevent worsening of disease and preserve vision. This mini-review describes the acute and chronic findings in SJS/TEN and discusses medical and surgical management strategies.

The Role of IL-13, IL-15 and Granulysin in the Pathogenesis of Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis.

Stevens-Johnson Syndrome (SJS) and toxic epidermal necrolysis (TEN) are Severe Cutaneous Adverse Reactions (SCARS) characterized by fever and mucocutaneous lesions leading to necrosis and sloughing of the epidermis. Conjunctival lesions are reported in 85% of patients. The pathogenesis of SJS/TEN/SCARS is not completely understood. It is hypothesized that IL-13, IL-15 and Granulysin expressed in plasma and skin may play a role. We measured the circulating levels of these cytokines in the plasma using ELISA and their expression in the skin using immunofluorescence microscopy. A total of 12 SJS/TEN skin biopsy samples (8 SJS, 2 SJS/TEN overlap and 2 TEN) were analyzed. Biopsy samples from patients with Lichen Planus (an inflammatory condition of the skin and mucous membranes) served as controls. Studies were also performed in human corneal epithelial cells where expression of these cytokines were measured following a challenge with TNF-α (0, 1, 10 and 100 ng/ml). The intensity of immunofluorescence was measured Using Imaris® software. The results showed significantly increased expression of these cytokines in the skin biopsy samples as measured by the average intensities of IL-13 (6.1 x 133.0 ± 4.231 x 10^8), and Granulysin (4.2 x 123.0 ± 4.231 x 10^8) compared to Lichen planus control (3.0 x 123.0 ±1.62 x 10^5). Increased expression of IL-13 and IL-15 were noted in cell culture studies and in the plasma samples when compared to Normal Human Plasma as controls. It is concluded that IL-13, IL-15 and Granulysin play a role in the pathogenesis of SJS/TEN.

Assessing the ocular surface microbiome in severe ocular surface diseases.

PURPOSE: There is growing evidence for a critical role of the microbiome in ocular health and disease. We performed a prospective, observational study to characterize the ocular surface microbiome (OSM) in four chronic ocular surface diseases (OSDs) and healthy controls. METHODS: Sterile swabs were used to collect samples from each eye of 39 patients (78 eyes). Sterile technique and multiple controls were used to assess contamination during DNA extraction, amplification and sequencing. Concurrent use of topical antibiotics, steroids, and bandage contact lenses (BCLs) was documented. RESULTS: Despite the low biomass of the ocular surface, 47/78 (60%) eyes sampled had positive sequencing reads. We observed that half of patients (8/17, 47%) had distinct microbiomes in each eye. Healthy controls had a Lactobacillus/Streptococcus mixture or significant Corynebacterium. Staphylococcus predominated in 4/7 (57%) patients with Stevens-Johnson Syndrome (SJS) in at least one eye, compared to 0/10 healthy controls. Interestingly, 8/11 (73%) eyes with SJS were using BCLs, including 4/5 (80%) eyes dominated by Staphylococcus. Lax eyelid syndrome (LES) and Dry Eye Disease (DED) patients had similar OSMs, with Corynebacterium being the most prevalent bacteria. Alpha diversity was higher in controls and ocular graft-vs-host (oGVHD) patients compared to the other OSDs. CONCLUSIONS: Only 50% of the 39 patients had similar microbiomes in each eye. A majority of healthy eyes had a Lactobacillus/Streptococcus mix or Corynebacterium microbiome. Staphylococcus predominated in SJS, Lactobacillus in oGVHD, and Corynebacterium in DED and LES. There may be an association between different OSDs and the microbiome.

Inflammation and oxidative stress induced by lipid peroxidation metabolite 4-hydroxynonenal in human corneal epithelial cells.

PURPOSE: Oxidative stress is widely known to be a major contributor in the pathogenesis of dry eye disease (DED). 4-Hydroxynonenal (4-HNE), a well-known byproduct frequently measured as an indicator of oxidative stress-induced lipid peroxidation, has been shown to be elevated in both human and murine corneal DED samples. This study aims to investigate if 4-HNE is responsible for the oxidative stress in human corneal epithelial cells (HCECs) and explores the underlying mechanism by which it confers its effects. METHODS: SV40-immortalized HCECs were cultured in minimum essential media (MEM) with 1% penicillin/streptomycin and 10% fetal bovine serum. HCECs were exposed to media with or without 4-HNE and cell culture supernatants were collected at 4 and 24 h. Cellular reactive oxygen species (ROS) measurement was performed using a 2',7'-dichlorofluorescein diacetate (DCFDA) assay kit according to the manufacturer's instructions. Protein levels of antioxidant enzymes copper/zinc superoxide dismutase 1 (SOD1) and NAD(P)H quinone dehydrogenase 1 (NQO1) were analyzed by Western blot. NF-κB activation and expression of IL-6 and IL-8 were measured using an NF-κB p65 Total SimpleStep ELISA Kit and Proteome Profiler Human Cytokine Array Kit. Cell viability was evaluated by LDH cytotoxicity assay. RESULTS: Treatment with 4-HNE decreased cell viability of HCECs. Band intensities corresponding to levels of ROS production showed a significant increase in ROS generation after treatment with 4-HNE. 4-HNE decreased SOD1 levels and upregulated NQO1 expression in HCECs. A significant increase in activation of NF-κB and production of pro-inflammatory cytokines IL-6 and IL-8 was observed after treatment with 4-HNE. Exposure to N-acetylcysteine (NAC), an antioxidant and ROS scavenger, antagonized the oxidative effects of 4-HNE on HCECs. CONCLUSION: 4-HNE induces oxidative stress in corneal epithelial cells by increasing levels of ROS generation and modifying the expression of antioxidant enzyme levels, decreasing cell viability of HCECs in vitro. This study demonstrates a potential pathway by which 4-HNE functions to confer its detrimental effects and provides a new therapeutic target for the treatment of DED.

SJS/TEN 2019: From science to translation.

Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN) are potentially life-threatening, immune-mediated adverse reactions characterized by widespread erythema, epidermal necrosis, and detachment of skin and mucosa. Efforts to grow and develop functional international collaborations and a multidisciplinary interactive network focusing on SJS/TEN as an uncommon but high burden disease will be necessary to improve efforts in prevention, early diagnosis and improved acute and long-term management. SJS/TEN 2019: From Science to Translation was a 1.5-day scientific program held April 26-27, 2019, in Vancouver, Canada. The meeting successfully engaged clinicians, researchers, and patients and conducted many productive discussions on research and patient care needs.

The Role of Multisystem Disease in Composition of Autologous Serum tears and ocular surface symptom improvement.

PURPOSE: Autologous serum tears (AST) contain growth factors and vitamins similar to those in healthy tears and are an effective treatment option for ocular surface disease. This study determined the differences in composition of AST in patients with systemic diseases versus patients with localized ocular surface diseases and the effects on ocular surface symptom improvement. METHOD: An observational study was performed on 53 patients with either systemic diseases (Group I) or localized ocular surface diseases (Group II) who were prescribed AST. Concentrations of epidermal growth factor (EGF), interleukin 8 (IL-8), fibronectin, vitamin A, and tumor necrosis factor-α (TNF-α) were determined through ELISA assays from patients in both groups. The Ocular Surface Disease Index (OSDI) scores were calculated prior to and 6 weeks after initiation of treatment with AST for new patients. RESULTS: The average concentration of EGF in Group I (29.39 pg/ml ± 52.85 pg/ml) was significantly lower than in Group II (88.04 pg/ml ±113.75 pg/ml) (p < 0.05). Levels of fibronectin, IL-8, and vitamin A were similar in both groups. There was a 24% reduction in OSDI score 6 weeks after initiation in Group I compared to a 36% reduction reported in Group II (p = 0.065). The OSDI score was reduced significantly after the treatment in all subjects (p = 0.002). CONCLUSION: Serum tears are a promising therapy for management of ocular surface disease and associated symptoms. The differences between levels of EGF in patients with localized ocular surface disease and systemic inflammatory disease may account for differences in therapeutic outcome.

Infectious interface keratitis (IIK) following lamellar keratoplasty: A literature review.

PURPOSE: The purpose of this study was to review the published incidence, etiology, clinical features and management of patients who developed infectious interface keratitis (IIK) following lamellar keratoplasty. DESIGN: This study is a systematic literature review. METHODS: We conducted a systematic review of published Chinese and English report through a PubMed search with the medical subject headings using the following terms: corneal transplantation, keratoplasty, anterior lamellar keratoplasty (ALK), deep anterior lamellar keratoplasty (DALK), deep lamellar endothelial keratoplasty (DLEK), Descemet membrane endothelial keratoplasty (DMEK), Descemet stripping endothelial keratoplasty (DSEK), Descemet stripping automated endothelial keratoplasty (DSAEK), infectious interface keratitis (IIK), fungal keratitis, and bacterial keratitis. Data collected included patient demographics, surgical technique, clinical signs, treatment, outcomes, and donor rim cultures. A review of the relevant literatures was also undertaken. RESULTS: From 2007 to Feb. 2018, we identified 62 cases of IIK following lamellar corneal surgery. The mean age was 26.95 ±â€¯8.80 years with a male/female ratio of 11:8 in DALK/ALK group and 69.65 ±â€¯8.00 years with a male/female ratio of 17:16 in DSAEK/DSEK/DMEK group (no gender information for 10 cases). Of the 62 cases, 46 cases (75.41%) were fungal, 9 cases (14.75%) were bacterial, 2 cases (3.28%) were Actinomyces species, 1 case (1.64%) was acanthamoeba, and 4 cases (6.56%) were indeterminant. The mean onset of symptoms was postoperative day (POD) 49.47 ±â€¯48.56 in DALK/ALK group, and 53 ±â€¯112.01 in EK group, and 62.44 ±â€¯50.07 for the bacterial keratitis, and 51.5 ±â€¯102.42 for fungal keratitis. The mean postoperative follow-up period was 10.10 ±â€¯9.36 months in DALK/ALK group and 12.37 ±â€¯12.28 months in DSAEK/DSEK/DMEK group. Of the total 62 cases, 1 case (1.61%) with a Klebsiella pneumoniae positive donor rim cultures was associated with the same pathogen in the IIK, and 16 cases (25.81%) of fungal positive donor rim cultures were associated with the same pathogen in the IIK. Clinical signs included conjunctival injection, interface opacity, stromal edema for bacterial keratitis, and dense white infiltrates at the interface with endothelial plaques in some cases of fungal keratitis. Medical treatment included topical and oral antimicrobial agents. Surgical interventions included therapeutic keratoplasty. In 15 cases (24.19%), medical management was successful. Of the remaining 47 cases, 8 (12.90%) were managed with a repeat lamellar keratoplasty (LK) and 39 (62.90%) were unresponsive to conservative medical treatment and underwent a therapeutic keratoplasty (TKP). Post infectious best corrected visual acuity (BCVA) was logMAR 0 in 7 eyes (11.29%), better than or equal to logMAR 0.4 in 20 eyes (32.26%), less than logMAR 0.4 in 22 eyes (35.48%) and logMAR 0.7 or worse in 13 eyes (20.97%). In the rim culture negative group(n = 19), the average BCVA was logMAR 0.59 ±â€¯0.68, with was logMAR 0.44 ±â€¯0.74 in rim culture positive group (n = 15). There were three recurrence cases were reported after DMEK during the postoperative follow-up period. CONCLUSIONS: Infectious interface keratitis (IIK) is an uncommon complication of lamellar keratoplasty, but it can result in a substantial loss of vision or permanent blindness. Although graft infection can occur at any time following surgery, it most commonly (87%) occurred during the first 3 months postoperatively (54/62 cases). The most commonly reported causative organism of IIK following lamellar keratoplasty was C. albicans. Positive rim culture results can provide more rapid and appropriate treatment directed to the identified organism. Therapeutic keratoplasty (TKP) was the most common surgical procedure for the management of IIK. Visual outcomes post TKP are fair with 32.26% (20/62) of patients obtaining LogMAR 0.4 or better.

Staged ocular fornix reconstruction for glaucoma drainage device under neoconjunctiva at the time of Boston type 1 Keratoprosthesis implantation.

PURPOSE: Glaucoma is the leading cause of vision loss in eyes with Boston Keratoprosthesis (KPro). Glaucoma drainage devices (GDDs) have been shown to be effective in controlling glaucoma with KPro. Cicatricial conjunctival disease with forniceal shortening is a major challenge and limitation to the use of GDD. In our series, we report the success of fornix reconstruction in cicatricial ocular surface disease as a staged procedure prior to a combined KPro/GDD surgery. METHODS: Retrospective case series involving 4 eyes with surface cicatricization. Three patients with chemical burns and one patient with Ectrodactyly Ectodermal Dysplasia-Clefting syndrome. Preoperative data, surgical interventions, and clinical outcomes were reviewed. CONCLUSION: This series represents the first report of fornix reconstruction for combined KPro/GDD surgery. Fornix reconstruction with the aid of AMT with or without OMM grafting is a relatively safe and effective way to manage complex cicatricial surface disease associated with corneal scarring and glaucoma, allowing for subsequent successful implantation of GDD and KPro in cases that were otherwise poor surgical candidates.

A Multicenter Study Evaluating the Risk Factors and Outcomes of Repeat Descemet Stripping Endothelial Keratoplasty.

PURPOSE: Descemet stripping endothelial keratoplasty (DSEK), currently the most common procedure for managing corneal endothelial dysfunction, may be repeated following DSEK failure from a variety of causes. This multicenter study reports the risk factors and outcomes of repeat DSEK. METHODS: This was an institutional review board-approved multicenter retrospective chart review of patients who underwent repeat DSEK. Twelve surgeons from 5 Midwest academic centers and 3 private practice groups participated. The Eversight Eye Bank provided clinical indication and donor graft data. We also assessed the role of the learning curve by comparing cohorts from the first and second 5-year periods. RESULTS: A total of 121 eyes from 121 patients who underwent repeat DSEK were identified. The average age of the patients was 70 ± 12 years. The most common indication for repeat DSEK was late endothelial graft failure without rejection (58%, N = 63). Average preoperative and 12-month postoperative repeat DSEK corrected distance visual acuities were 20/694 and 20/89, respectively. Visual acuity outcomes, endothelial cell density, and cell loss did not significantly vary between the 2 cohorts. Initial graft rebubble rates for the first and second cohorts were 51% and 25%. The presence of glaucoma, prior glaucoma surgery, or a history of penetrating (full thickness) keratoplasty did not significantly affect visual outcomes. The median, mean, and range of intraocular pressures before repeat DSEK were 15.0, 15.7, and 6 to 37 mm Hg, respectively. Patients with higher intraocular pressures before repeat DSEK had improved postoperative corrected distance visual acuities. CONCLUSIONS: Repeating DSEK improves vision following failed or decompensated DSEK surgery. Higher preoperative repeat DSEK IOPs were associated with improved visual outcomes, and initial graft rebubble rates, which decreased over time, were likely due to surgeon experience.

Lax eyelid syndrome (LES), obstructive sleep apnea (OSA), and ocular surface inflammation.

PURPOSE: Lax eyelid syndrome (LES) is defined as the association of distensible "floppy" eyelids and chronic papillary conjunctivitis. LES is also found in patients with obstructive sleep apnea (OSA) who have systemic elevation of inflammatory markers, including matrix metalloproteinases (MMP). Locally elevated MMP levels have also been demonstrated co-localized with elastin loss in eyelids of patients with LES, accounting for their "floppiness." The purpose of this study was to investigate tear film MMP levels and determine their association with eyelid laxity and OSA. We also evaluated 3 previous grading systems to determine the severity of lid laxity and introduced a new "laxometer" device. METHODS: Thirty-seven subjects underwent bilateral eyelid laxity assessments prior to polysomnography testing. OSA severity was graded using the apnea hypopnea index (AHI). The degree of eyelid laxity was determined using three published methods and a newly proposed "laxometer" method. Commercially available InflammaDry® kits were used to determine the presence of MMP-9 in the tear film. RESULTS: There was a significant elevation in tear MMP-9 levels in patients with LES compared to controls (p < .05). Of the 37 total patients enrolled in this study, 2 patients (5.4%) did not have sleep study results. Thirty-two of the remaining 35 patients (91.4%) were determined to have OSA (AHI > 5). In this sample, there was no meaningful association between OSA and MMP-9 (p = .12). Although there were positive associations between OSA severity, laxometer measurements, and previously established grading methods, none achieved statistical significance (all p > .05). CONCLUSIONS: There was an elevation of MMP-9 in tears of patients with LES. Elevated tear MMP-9 was also not associated with OSA. Although there is some evidence to support the association of eyelid laxity and OSA, the most accurate and reliable method for grading eyelid laxity remains unclear.