Patient-reported outcomes of autologous serum tears for the treatment of dry eye disease in a large cohort.

PURPOSE: To assess patient satisfaction with autologous serum tears (AST) for the treatment of dry eye disease (DED). METHODS: A prospective, observational case-series, including 100 participants who were treated with AST for DED. The five-item Dry Eye Questionnaire (DEQ-5), Symptom Assessment in Dry Eye (SANDE) Questionnaire, and the Treatment Satisfaction Questionnaire for Medication (TSQM) were used to assess DED symptoms and patients' treatment satisfaction. RESULTS: The duration of AST treatment was 1-6 months in 25%, 6-12 months in 24%, 1-2 years in 22%, and 2-3 years in 29% of the participants. The mean cumulative DEQ-5 score was 12.7 ±â€¯3.8 and 65% of the participants scored ≥12, which may suggest an underlying diagnosis of Sjögren's syndrome. The use of other treatments was significantly reduced after the use of AST (P < 0.001). The mean total SANDE score improved from 79.5 ±â€¯21.8, 95% CI [75.2, 83.8] before to 42.2 ±â€¯23.2, 95% CI [37.6, 46.8] after using AST (P < 0.001). The mean TSQM treatment efficacy, convenience, and global satisfaction scores were 73.1 ±â€¯17.2, 95% CI [69.6, 76.5], 72.5 ±â€¯17.5, 95% CI [69.0, 76.0], and 74.6 ±â€¯22.7, 95% CI [70.1, 79.0]. No patients reported any side effects. CONCLUSION: Autologous serum tears treatment in severe dry eye disease significantly reduced dry eye symptoms, with high patients' satisfaction scores.

Half top hat wound configuration for penetrating keratoplasty: 1-year results.

AIMS: To compare the 1-year outcomes after half-top-hat (HTH) penetrating keratoplasty (PK) versus top-hat (TH) PK and regular PK. METHODS: We reviewed the clinical notes of 87 consecutive patients who had undergone either HTH PK (23 eyes), TH PK (36 eyes) or regular PK (35 eyes) at Toronto Western Hospital between 2002 and 2007. We evaluated best-corrected visual acuity (BCVA), topographic and refractive results, high-order ocular aberrations, endothelial cell counts and complication rates. RESULTS: The three groups of patients did not differ significantly in their demographics (age, gender and laterality), donor endothelial cell counts, preoperative visual acuity or intraocular pressure (IOP). At 12 months postoperatively, BCVA was similar in the three groups, as was the mean spherical equivalent and cylinder. The time to sutures removal was significantly shorter in the HTH PK versus regular PK groups (3.8 (1.2) vs 9.7 (1.1) months, p<0.0001), and the endothelial cell counts were significantly higher (p = 0.003). The IOP was higher in the HTH PK patients than in regular PK patients (p = 0.04). All high-order aberrations tested were significantly higher in the HTH PK than in the regular PK groups (p<0.01). Regular PK had a higher rate of astigmatism treated with relaxing incisions (n = 7 vs n = 2 in HTH PK) and dehiscence of wound incision (n = 2, versus n = 0 in HTH PK). CONCLUSIONS: BCVA and refractive results are similar after half-top-hat, top-hat and regular PK. Half-top-hat PK substantially speeds up visual recovery and contributes to significantly higher endothelial cell counts in the grafts 1 year after surgery.

Fibrin glue versus sutures for attaching the conjunctival autograft in pterygium surgery: a prospective observer masked clinical trial.

AIMS: To compare the degree of conjunctival autograft inflammation, subconjunctival haemorrhage (SCH) and graft stability following the use of sutures or fibrin glue (FG) during pterygium surgery. METHODS: Prospective, observer masked, clinical trial. 40 eyes of 40 patients undergoing primary pterygium surgery with conjunctival autograft were allocated into two groups. Group 1 (n = 20) had FG (Tisseel) for attaching the conjunctival autograft, whereas group 2 (n = 20) had sutures. Standardised digital slit-lamp photographs were taken at 1 week, 1 month and 3 months postoperatively. Sutures were masked using commercially available photo-editing software. Two masked observers objectively graded the digital photographs for degree of inflammation, SCH and graft stability. RESULTS: 34 of the 40 patients completed the study. When using FG, the degree of inflammation was significantly less than with sutures at 1 month (p = 0.019) and 3 months (p = 0.001) postoperatively. No significant difference was found for inflammation at 1 week postoperatively (p = 0.518). Conjunctival grafts secured with FG were as stable as those secured with sutures (p = 0.258, p = 0.076 and p = 0.624, at 1 week, 1 month and 3 months, respectively). No significant difference was found in degree of postoperative SCH between the groups (p = 0.417, p = 1 and p = 1, at 1 week, 1 month and 3 months, respectively). CONCLUSION: This is the first prospective clinical trial confirming that conjunctival grafts secured with FG during pterygium surgery not only are as stable as those secured with sutures, but also produce significantly less inflammation.

Femtosecond laser versus manual dissection for top hat penetrating keratoplasty.

AIM: To compare the outcomes of IntraLase-enabled top hat penetrating keratoplasty (IEK) versus retrospective results of manual top hat penetrating keratoplasty (TH-PKP) and conventional PKP. PATIENTS/METHODS: This non-randomised prospective study included 94 eyes: 23 eyes underwent IEK, 36 TH-PKP and 35 conventional PKP. Preoperative and postoperative manifest refraction, uncorrected and best-spectacle corrected visual acuity (BSCVA), high-order ocular aberrations (HOA), endothelial cell counts and complications were analysed. RESULTS: At 12 months of follow-up, the mean log MAR BSCVA was 0.32 (SD 0.31) in the IEK group, 0.53 (0.36) in the TH PKP group (p = 0.03) and 0.39 (0.30) in the conventional PKP group (p = 0.4). The mean spherical equivalent was similar between the groups and was less than -2.2 dioptres. The mean cylinder was similar in the IEK and conventional PKP group (3.6 (1.9) dioptres and 4.1 (1.8) dioptres, respectively), and was significantly lower than the TH-PKP group (5.1 (3.2) dioptres, p = 0.04). The complications rate and high-order ocular aberrations were similar between the three groups studied. The mean endothelial cell loss was significantly lower at 12 months of follow-up in the IEK and the TH-PKP groups versus conventional PKP (32.4% and 22.3% vs 40.8%, respectively) (p = 0.05). The mean time to suture removal was 4.1 (1.2) months in the IEK group and 3.9 (1.5) months in the TH-PKP group versus 9.7 (1.1) months in the conventional PKP group (p<0.0001). CONCLUSIONS: IEK is a safe and stable procedure. It results in higher endothelial counts and faster suture removal in comparison with the conventional PKP, and has less astigmatism and better BSCVA in comparison with the manual TH-PKP.

Corneal wound malapposition after penetrating keratoplasty: an optical coherence tomography study.

AIMS: To examine the wound configuration after penetrating keratoplasty (PKP) using anterior segment optical coherence tomography (OCT). METHODS: All PKP patients who were examined for routine follow-up, between November and December 2006, after having all their sutures removed were included. Patients underwent clinical examination, refraction, corneal topography, aberrometry and Visante anterior segment OCT. RESULTS: 204 graft-host sections from 27 eyes (25 patients, mean age 51.6 (SD 17.7) years) were analysed. Although all the graft-host junctions had continuous smooth epithelial surfaces, 124 of them (60.8%) had internal graft-host malappositions such as gapes (15.7%), steps (30%) or protrusions (15.2%). Keratoconus patients had significantly more graft steps (p<0.05) while those transplanted for endothelial dysfunctions had more protrusions (p<0.01). Graft oversizing significantly increased the size of malappositions. Internal gapes or steps significantly reduced the graft-host touch. Intraocular pressure (IOP), final refraction and final keratometric cylinder were all significantly correlated with the presence and size of the malapposition, while steeper keratometry and tilt aberrations correlated with diminished graft-host touch. CONCLUSIONS: After PKP, internal graft-host malapposition is relatively common and associated with increased ametropia, astigmatism, IOP and optical tilt aberrations.

Half-top-hat--a new wound configuration for penetrating keratoplasty.

AIMS: To describe a new, simpler method of achieving the advantages of a lamellar wound configuration in penetrating keratoplasty (PKP)--the half-top-hat (HTH) configuration. METHODS: The donor corneal button was prepared in a top-hat configuration, as previously described. It consisted of a central, full-thickness part, 7-8 mm in diameter, surrounded by a peripheral lamellar wing of deep stroma and endothelium that was 0.5 mm in width (wing diameter 8-9 mm). The recipient bed was prepared by a straight full thickness trephination with a suction trephine. The donor button was positioned by sliding the peripheral wing under the recipient bed. Sixteen 10-0 interrupted sutures and a single continuous 16-bite 11-0 nylon sutures were placed. The interrupted sutures were passed so as to go through the wing, in order to ensure a good apposition of the wing to the inner corneal surface of the recipient. Anterior segment optical coherence tomography (Visante OCT) was used to image the position and alignment of the corneal graft postoperatively. RESULTS: Ten eyes of 10 patients (mean (SD) age: 73.7 (11.4) years, 7 females) underwent HTH PKP. The donor lenticule diameter was 7.7 (0.3) mm (wing diameter 8.7 (0.3) mm). The mean follow-up time was 2.4 (0.7) months. The last median visual acuity was 20/200 (range 20/80-counting fingers), and the last IOP was 18.2 (8.8) mm Hg. No major intraoperative complications were noted. No postoperative events of graft rejection were documented. No anterior surface misalignment was noted either clinically or by OCT. One patient had a rise in IOP postoperatively. CONCLUSIONS: Half-top-hat wound configuration is a valid alternative in penetrating keratoplasty. Its advantages include better apposition of donor and recipient corneas, improved tectonic strength to prevent graft dehiscence, the possibility of early sutures removal and being a simpler procedure to perform.

Clinicopathological correlation of congenital corneal opacification using ultrasound biomicroscopy.

AIM: To investigate the correlation between clinical, high frequency ultrasound biomicroscopy (UBM) and, where possible, histological findings in cases of congenital corneal opacification presenting to the departments of ophthalmology, Great Ormond Street Hospital for Children, London, and the Hospital for Sick Children, Toronto, Canada. METHOD: 22 eyes of 13 children (age range 3-225 days) with congenitally opaque corneas were examined. UBM was performed using the ultrasound biomicroscope (Allergan-Humphrey). All eyes underwent penetrating keratoplasties (PKP) except five. The host corneas were all sent for histological examination. RESULTS: The final diagnosis in our series was Peters' anomaly in nine cases (70%), corneal dystrophy in two cases (15%), and sclerocornea in two cases (15%). The UBM findings changed the clinical diagnosis in five cases (38%). In these five cases histology was available in four and confirmed the UBM diagnosis in each case. In no case of the 13 where histology was available did it contradict the UBM findings. In two cases a hypoechoic region in the anterior stroma was seen on UBM which correlated histologically with absent Bowman's layer and oedema. In two cases UBM revealed aniridia and in one, congenital aphakia, which was not apparent clinically. CONCLUSION: UBM examination is not only very useful in evaluating the clinical diagnosis in congenital corneal opacification, it also acts as a preoperative guide in cases undergoing PKP by detecting keratolenticular and iridocorneal adhesions and other ocular abnormalities such as aniridia and congenital aphakia. In all cases where PKP was performed the UBM diagnosis was confirmed histologically. The clinical diagnosis was incorrect in five cases. This has important implications in studies of phenotype/genotype correlation of congenital corneal opacification.

Corneal temperature reversal after storage in Chen medium compared with Optisol GS.

PURPOSE: To compare corneal endothelial cell function by measuring corneal thickness during temperature reversal between corneas stored in two different storage media, Optisol GS and Chen Medium (CM). METHODS: Twenty paired corneas from 10 human donors were randomly assigned for storage at 4 degrees C in Optisol GS (10 corneas) or CM (10 corneas). The storage media were masked, and measurements were done in a masked fashion. After storage for 48 hours, corneal thickness was measured by ultrasonic pachymetry at 2-hour intervals for 12 hours, during which time the corneas were perfused with BSS (balanced salt solution) Plus at 37 degrees C. Scanning electron microscopy of two pairs of corneas from two donors was performed to assess ultrastructural change after 12 hours of warming. RESULTS: Corneal thickness decreased during the first 4 hours of the warming period and then increased during the 6-to 12-hour warming period. These changes in corneal thickness over time were similar for the two storage media (p = 0.212). Scanning electron microscopy showed greater amounts of endothelial cell disruption in Optisol GS-stored corneas than those stored in CM after 12 hours of warming and perfusion. CONCLUSIONS: The endothelial pump of corneas stored in CM appear to be as well-preserved as those stored in Optisol GS, although greater endothelial disruption may be present with Optisol GS by scanning electron microscopy. Further studies are required to compare the clinical effectiveness of these two media.

Detection of hepatitis C virus in the corneas of seropositive donors.

PURPOSE: There have been no reported cases of hepatitis C virus (HCV) transmission by corneal transplantation. Previous studies have also shown no correlation between HCV seropositivity and the presence of HCV RNA in the corneal tissues. This study aims to investigate such correlation and to provide further evidence to the possible transmissibility of HCV via corneal grafts. METHODS: Of the 1,619 potential corneal donors to the Eye Bank of Canada over a 1-year period, 15 tested HCV-positive by the second-generation Abbott HCV enzyme immunoassay (EIA) 2.0 assay. Their sera were further tested with second-generation radio-immunoblot assay (RIBA-II), and their corneas (29 altogether) were processed for identification of HCV RNA using polymerase chain reaction (PCR). RESULTS: Of the 29 corneas from seropositive donors, HCV RNA was detected in 7 (24.1%). CONCLUSION: This is the first study in the literature that demonstrates a significant correlation between HCV seropositivity and the presence of HCV in the corneas. Routine HCV serologic testing for all potential corneal donors and rejection of corneal tissues based on HCV seropositivity is certainly justifiable.

Dislocation of a plate-haptic silicone intraocular lens into the anterior chamber.

Posterior dislocation is a well-described complication of plate-haptic intraocular lenses (IOLs). It usually occurs after an opening in the posterior capsule, either intraoperatively or after a neodymium: YAG capsulotomy occurs. We report a case of anterior luxation of a plate-haptic silicone IOL occurring 4 months after uneventful cataract surgery. This case emphasizes the need for a small and continuous capsulorhexis as well as in-the-bag implantation of plate-haptic IOLs.

Foldable silicone versus poly(methyl methacrylate) intraocular lenses in combined phacoemulsification and trabeculectomy.

PURPOSE: To compare the outcome of phacotrabeculectomy with implantation of poly(methyl methacrylate) (PMMA) or foldable silicone intraocular lenses (IOLs). METHODS: Thirty patients were randomized to receive a 5.5 mm PMMA IOL through a 5.0 mm incision or a foldable silicone IOL (Allergan SI-30) through a 3.2 mm incision. Visual acuity, intraocular pressure (IOP), bleb survival, inflammation, endothelial cell changes, and complications were examined at intervals up to 6 months. RESULTS: There was no difference between the 2 groups in final visual outcome, final IOP control, bleb survival, and endothelial cell changes. Two months after surgery, there was significantly more inflammation in the silicone IOL group than in the PMMA group (P <. 05). The silicone group had a significantly higher combined complication rate including iris capture, choroidal effusion, and epiretinal membrane formation (P <.05). CONCLUSIONS: Foldable silicone IOLs were comparable to conventional PMMA lenses in visual outcome, IOP control, bleb formation, and endothelial changes. However, some silicone lenses are associated with an increased risk of recurrence of inflammation and a higher final complication rate in combined cataract and filtration surgery.

Long-term results of transscleral Nd:YAG cyclophotocoagulation for refractory glaucoma postpenetrating keratoplasty.

PURPOSE: To determine the effects of noncontact transscleral Nd:YAG cyclophotocoagulation (NCTY) in the treatment of refractory glaucoma postpenetrating keratoplasty (PKP) with respect to intraocular pressure (IOP), corneal graft survival, and reduction of glaucoma medications. METHODS: The records of all patients treated with NCTY for refractory glaucoma after PKP at the authors' institution over an 11-year interval were reviewed. The LASAG noncontact Nd:YAG laser (Lasag AG; Thun, Switzerland) was used. Approximately 40 laser applications were delivered per eye. Visual acuity, IOP, glaucoma medications, and corneal graft clarity were evaluated. RESULTS: Fifty-two eyes met the inclusion criterion. The mean pretreatment IOP was 38.7+/-11.9 mm Hg. The mean posttreatment IOP was 15.8+/-9.7 mm Hg. From life table analysis, the probability of having a posttreatment IOP of 21 mm Hg or less with or without medication was 70% at 1 year and 63% at 5 years. The probability of a graft remaining clear was 79% at 1 year and 56% at 5 years. In 85% of patients the visual acuity remained stable, in 11% the visual acuity improved, and in 4% the visual acuity deteriorated after treatment. One patient developed hypotony. Twenty patients (36.5%) were able to discontinue one or more glaucoma medications posttreatment. CONCLUSION: In this group of patients with PKP glaucoma, NCTY effectively lowered IOP over the long term, with 36.5% of patients discontinuing one or more glaucoma medications. There was, however, a significant incidence of graft failure at 5 years.

Primary localized conjunctival amyloidosis presenting with recurrence of subconjunctival hemorrhage.

PURPOSE: To report the ocular presentation and histopathology of a patient with primary localized conjunctival amyloidosis. METHODS: A 38-year-old woman presented with a recurrence of episodes of severe bilateral subconjunctival hemorrhage. Ocular examination revealed yellowish, marked folding and redundancy of the conjunctiva in the inferior cul-de-sac of each eye. RESULTS: After two initial conjunctival biopsies that showed only chronic inflammation, a third biopsy revealed the presence of amyloid in the substantia propria of the conjunctiva. CONCLUSION: Primary localized conjunctival amyloidosis is rare and usually diagnosed histologically instead of clinically. Recurrence of subconjunctival hemorrhage may be the initial presentation. Evaluation for systemic diseases is advised, though the results of the examination are almost always negative.

Three decades of corneal transplantation: indications and patient characteristics.

PURPOSE: To review the indications and patient characteristics for penetrating keratoplasty (PKP). METHODS: Retrospective review of records at the Pathology Service, Department of Ophthalmology, University of Toronto from 1964 to 1997. RESULTS: The 6,222 records were reviewed. The leading indications for PKP were regraft, keratoconus (KC), pseudophakic bullous keratopathy (PBK), Fuchs' dystrophy, viral infections, and trauma, in that order. During the second half of the 1980s, PBK replaced KC as the leading indication for transplantation. The average age of patients increased from 49 (+/-19) years during the second half of the 1960s to 63 (+/-20) years at the first half of the 1990s. Gender differences (M/F ratio) were significant for KC, viral keratopathy, trauma, PBK, aphakic bullous keratopathy (ABK), edema of unspecified etiology, interstitial keratitis, rheumatoid arthritis, and Fuchs' dystrophy. Diagnostic category differences between all patients for PKPs and regrafts were significant for autoimmune keratolysis, congenital opacities, PBK, ABK, edema of unspecified etiology, scarring, Fuchs' dystrophy, and KC. CONCLUSION: Indications are in accordance with the literature with the exception of regraft, which was higher. An increase in the average age of patients corresponded with the PBK epidemic. The high male-to-female ratio among patients with KC was different from that previously reported for the prevalence of this condition. Sex distribution among patients with PBK and ABK showed a female predominance. Differences in the underlying disease distributions between regrafted patients and the rest of the series coincide with prognostic classifications for PKP.

Early intraocular pressure after phacoemulsification combined with trabeculectomy.

BACKGROUND AND OBJECTIVE: To determine the efficacy of combined phacoemulsification--trabeculectomy in preventing early postoperative increases in intraocular pressure (IOP). PATIENTS AND METHODS: Eighty patients were enrolled in a prospective cohort study. Thirty-six patients with cataracts and uncontrolled glaucoma underwent combined phacoemulsification--trabeculectomy, and 44 patients with cataracts underwent phacoemulsification alone. The operations were performed in a standardized manner by one surgeon. IOP was measured at 4 hours, 1 day, and 7 days after surgery. The need for intervention (digital massage, medications) and the presence of complications were documented. RESULTS: Four hours after surgery, 5.5% of patients undergoing the combined procedure had IOPs greater than 30 mm Hg, compared with 22.7% of phacoemulsification patients (P < .05). No significant difference in IOP was found between the groups at postoperative day 1 or day 7. CONCLUSION: These results suggest that combined phacoemulsification-trabeculectomy protects against early postoperative elevations in IOP. This finding may influence the surgical management of cataracts in patients with poorly controlled glaucoma and significant compromise of visual field or optic nerve.

Morin hydrate: a better protector than purpurogallin of corneal endothelial cell damage induced by xanthine oxidase and SIN-1.

PURPOSE: Free radicals are responsible for tissue injury in corneal preservation and transplantation. Morin hydrate, a flavonoid from Brazil wood, has been shown to be cytoprotective in several types of cells. The aim of this study was to investigate the effectiveness of morin hydrate on rabbit corneal endothelial cells against damage induced by oxyradicals and nitric oxide. METHODS: Corneal endothelial cell cultures were prepared from New Zealand white rabbits, using standard microcarrier technique. Two free-radical-generating systems were used-17 IU/L xanthine oxidase/1 mM hypoxanthine and 5 mM 3-morpholinosydnonimine-N-ethylcarbamide (SIN-1, a nitric oxide-donating agent). RESULTS: Over 95% of cultured corneal endothelial cells necrosed within 3.6 +/- 1.5 min after exposure to xanthine oxidase/hypoxanthine. Adding morin hydrate delayed cell necrosis to 5.8 +/- 0.3 min (0.25 mM morin hydrate), 13.3 +/- 5.0 min (0.5 mM), and 41.5 +/- 8.6 min (1.0 mM). Exposed to nitric oxide generated by SIN-1, cells necrosed by 9.5 +/- 2.5 min, versus 14.1 +/- 1.3 min (0.25 mM morin hydrate), 27.2 +/- 2.0 min (0.5 mM), and 43.3 +/- 5.4 min (1.0 mM). Morin hydrate significantly prolonged survival of cells compared to equimolar concentrations of purpurogallin, Trolox, or ascorbate (P < 0.01). CONCLUSION: This study demonstrates that morin hydrate behaves as a broad-spectrum antioxidant: it scavenges not only xanthine oxidase/hypoxanthine-generated oxyradicals, but also nonenzymatic, nitrogen-derived radicals, better than those above mentioned antioxidants. This property of morin hydrate may help prevent free radical damage in corneal preservation solutions.

Utilizing eye bank eyes and keratoplasty techniques to teach phacoemulsification.

Learning microsurgery can be a difficult task. Three techniques for practicing phacoemulsification using eye bank eyes, rigid contact lenses, and lamellar keratoplasty are described. These simple methods provide a realistic environment for learning and developing microsurgical skills.