A retrospective study of the efficacy of intense pulsed light delivered by the Lacrystim® for meibomian gland dysfunction therapy.

BACKGROUND: Meibomian gland dysfunction is the most common etiology of dry eye disease worldwide and intense pulsed light appears to be a promising treatment with encouraging results. Lacrystim® is a new IPL device (CE marking in 2019) and no studies have yet been published on it. We propose the first study on this device with an objective assessment of its efficacy and an extended follow-up over 6 months. METHODS: Patients presenting with a dry eye disease (DED) with stable mild to moderate MGD and having received Lacrystim® treatment between june 2019 and june 2020 were included. 3 IPL sessions were performed at D0, D15 and D45 with 4 shots per side at a fluence of 8 mJ/cm2. DED clinical evaluation was performed at D0, D15, D45, 3rd month and 6th month: Oxford scale and break up time, Schirmer test and Ocular Surface Disease Index (OSDI) questionnaire. Lacrydiag® imaging device carried out an objective examination of tear film: interferometry, meibography, tear meniscus height and non-invasive break up time (NIBUT). The primary endpoint was the evolution in NIBUT between the first visit D0 and 3rd month. Data collection was done retrospectively. Statistical analysis was done using a linear mixed-effects model and a non-parametric linear mixed-effects model (R software). RESULTS: Forthy five consecutive patients were included. NIBUT significantly increased between D0 and 3rd month: mean difference of 1.63 seconds, IC95% [0.51; 2.62], (p = 0.002) with a prolonged effect at 6th month. OSDI and OXFORD scores and interferometry were also significantly improved at 3rd month and 6th month. There was no significant change in BUT, Schirmer test and tear meniscus height. No adverse event was noted. CONCLUSIONS: IPL delivered by Lacrystim® appears effective and safe to treat MGD although a randomized controlled trial is needed to validate its results. TRIAL REGISTRATION: This work was approved by a local ethics committee "Terre d'éthique" (institutional review board number: IRBN672019/CHUSTE) and registered on the clinicaltrial.gov website ( NCT04147962 , 01/11/2019).

Repeat corneal transplantation: indication, surgical technique, and early graft failures trends in France from 2004 to 2019.

PURPOSE: To investigate the repeat corneal transplantation trend in France from 2004 to 2019. METHODS: Review of the prospectively compiled French Biomedicine Agency electronic database containing all corneal transplantation records from 2004 to 2019. The surgical technique, demographic characteristics, diagnosis, and previous graft data were retrieved and analyzed using the Cochran-Armitage trend test. RESULTS: A total of 66,584 corneal transplantations were performed, 51,260 of which were first grafts and 15,324 (23%) were regrafts. For regrafts, 77% were penetrating keratoplasties (PK) and 19.6% were lamellar keratoplasties (LK). Age, hypertonia, glaucoma, trauma, lens surgery, immune disorders, diameter > 8.5 mm, and neovessels in > 2 quadrants were associated with a higher rate of repeat keratoplasty. Keratoconus, secondary endothelial dystrophy, and Fuchs' dystrophy were the principal indications for regrafting. When a previous graft failed, it occurred earlier for patients with LK (4.6 years, median = 2, SD = 7.54) than PK (8.48 years, median = 5, SD = 9.51). Failure within a year was the reason why 28.3% of the LK regrafts and 12.5% of PK regrafts were performed, while for failure within two years these values were 49.9% and 27.8%, respectively. Graft survival decreased with the number of repeat keratoplasty, being more pronounced after a second LK regraft and after a first PK regraft. CONCLUSION: The number of LK regrafts increased continuously, and 1/3 were performed for failure within the year. This rate increased until 2015, after which it stabilized until 2019, probably due to the better mastery of the technique.

Detection of refractive photokeratectomy traces during eye banking: impossible with organ culture but possible with an active storage machine: case report.

The detection of corneas operated on for refractive surgery [LASIK or photorefractive keratectomy (PRK)] will become a major concern for eye banks in the coming years because this surgery is often forgotten during the interview with the deceased's relatives. We present here 2 corneas operated on with PKR and stored successively in organ culture (OC) and in the active storage machine (ASM) that restores intraocular pressure, restores the cornea to its original shape, respects transparency and incorporates non-invasive controls. The 2 corneas of a 49-year-old donor operated 17 years earlier by PRK for -2 and -3 diopters myopia were stored in OC for 14 days and then placed in ASM for 48 h. Thickness map and OCT topography were performed under the 2 storage conditions, histology and electron microscopy were then performed. Traces of PRK remained unnoticed in OC while they were evident in ASM with central epithelial anomaly, central thinning and flattening of central keratometry shown by OCT. Histology and ultrastructure confirmed the absence of Bowman's membrane in the center. By placing the cornea under physiological conditions, and in particular by triggering its deswelling and by restoring its natural curvature, the ASM allows effective detection of subtle refractive surgery traces like those present after PRK.

Innovative corneal active storage machine for long-term eye banking.

Optimal ex vivo corneal storage in eye banks is crucial to increase both the number of corneas suitable for graft and their intrinsic quality, mainly the number of viable endothelial cells, which dictates graft survival in recipients. With both passive storage methods used worldwide (short-term cold storage in the United States, long-term organ culture in Europe), significant endothelial cell loss is inevitable. Here we show that, with an active storage machine, also called a bioreactor, which restores 2 fundamental physiological parameters, intraocular pressure and medium renewal, endothelial cell survival is improved by 23% compared with organ culture after 4 weeks' storage. Also observed in the bioreactor is a 4-fold higher expression of Na+ /K+ ATPase, which supports one of the major endothelial cell pumping functions. In addition, corneas remain thin and transparent, so they are suitable for surgery at any time. This new active eye banking method may help to reduce the severe global scarcity of donor corneas.

Considering 3D topography of endothelial folds to improve cell count of organ cultured corneas.

The posterior side of the cornea is covered by the endothelial monolayer, which governs corneal transparency but cannot proliferate. Determination of endothelial cell density (ECD) is therefore the minimal and mandatory quality control in all eye banks. It avoids primary graft failures caused by endothelial insufficiency, and allows allocation of corneas to surgical techniques requiring different numbers of endothelial cells (ECs). Corneas stored in organ culture (17% of grafts worldwide), are characterized by heavy stromal swelling and numerous deep endothelial folds, up to 200 µm high. During microscopic en face observation, flat surfaces are thus exceptional and EC counting is biased by parallax errors, resulting in overestimated eye bank ECD (ebECD). We used a motorized transmitted light microscope to acquire Z-stacks of images every 10 µm, and processed them to reconstruct the 3D surface of the folded endothelium. This method (3D-ECD) takes into account the local point-by-point slope in order to correct ECD. On a set of 30 corneas, we compared 3D-ECD and ebECD determined on five identical zones at the center of the cornea. 3D reconstruction allowed us to visualize twice as many cells, and ebECD was 8.1 ± 4.5% (95%CI 6.4-9.7) higher than 3D-ECD, with 1744 ± 488 versus 1606 ± 473 cells/mm2. 3D counting makes it possible to increase cell sampling and to correct overestimation by the conventional en face counting still routinely performed in eye banks.

Femtosecond laser-cut autologous anterior lens capsule transplantation to treat refractory macular holes.

BACKGROUND: To report the long-term outcomes of round autologous anterior lens capsules (ALCs) cut by a femtosecond laser (FSL) and transplanted onto refractory macular holes (MHs) in a prospective interventional study. METHODS: Three eyes of three patients were included for persistent MH after reattached rhegmatogenous retinal detachment (RRD) (n = 2) or RRD recurrence by persistent MH (n = 1), in a university hospital. A 6 mm diameter ALC disc was carefully extracted during FSL-assisted lens extraction, stained with 0.06% trypan blue, decellularised, transplanted using a catheter and unfolded over the MH. Gas or silicone-oil tamponade was used. At 1 year, the main criterion was anatomic success, defined as complete MH closure. Secondary criteria were changes in best corrected visual acuity (BCVA), ellipsoid zone (EZ) and external limiting membrane (ELM) defects, complications. RESULTS: Baseline data were: minimum and maximum diameters, respectively 887, 1079 and 1180 µm; 1260, 1213 and 1350 µm; central posterior staphyloma in two highly myopic eyes; number of prior surgeries 2 ± 1. At 1 year, the three MHs were closed with stable transplanted ALCs. Distant BCVA improved respectively from 3.0, 0.8, 3.0 to 1.0, 0.2, 0.7 logMAR, i.e. all eyes achieved ≥0.3 logMAR improvement. All patients had decreased EZ and ELM defects, without reaching normal profile. No adverse event occurred. CONCLUSIONS: FSL-cut ALC helps standardise this challenging surgery: it prevents from tears and facilitates manipulation, so that the ALC disc is perfectly transparent and biocompatible, with a large MH overlap. One-year follow-up highlighted that this technique helps safely close refractory MHs with satisfactory visual recovery.

Dropless penetrating keratoplasty using a subconjunctival dexamethasone implant: safety pilot study.

BACKGROUND/AIM: Rejection is the main cause of graft failure after penetrating keratoplasty (PK). Its prevention by repeated instillation of steroid eye-drops has not evolved in decades. Poor adherence and discontinuous nature of eye-drop treatment may explain some PK failures. In a rabbit model, we previously demonstrated that a subconjunctival dexamethasone implant was well tolerated and prevented rejection efficiently in the first 5-6 weeks. This clinical trial investigates its tolerance and safety after PK. METHODS: Single-centre, phase II non-randomised tolerance and safety pilot study (NCT02834260). Designed to analyse the risk of elevated intraocular pressure (IOP), discomfort and resorption time. Fourteen patients with a low rejection risk indication of PK were enrolled between January 2017 and August 2018. The implant was injected in the 12 o'clock position, 5 mm from the limbus, at the end of PK. A steroid eye-drop treatment was planned when implant resorption was complete. Patients were monitored regularly for 12 months: IOP (main outcome measure at 1 month), discomfort and redness scores, implant status, rejection episode and central corneal thickness by optical coherence tomography. An independent data safety monitoring committee verified safety aspects. RESULTS: No increase in IOP or other adverse event related to the implant was observed. Average resorption time was 6 weeks. The switch to steroid eye-drops was uneventful. One patient, included despite preoperative corneal neovascularisation (unintended protocol deviation) experienced a rejection. CONCLUSIONS: This is the first proof of concept that dropless immunosuppression is possible after low rejection risk PK. TRIAL REGISTRATION NUMBER: NCT02834260.

Treatment of Mechanical Corneal Wounds Emergencies during the COVID-19 Pandemic: Absorbable 10-0 Vicryl (Polyglactin 910) Sutures as a Suitable Strategy.

Background­The COVID-19 pandemic has changed our standard practices: operating rooms were only available for functional emergencies and outpatient visits were drastically reduced in favor of telemedicine. Aim: To report the personalized "one-shot" surgery using absorbable 10-0 Vicryl (V10-0) or polyglactin 910 monofilament in mechanical corneal injuries from February 2020 to December 2021. Methods­Prospective case series with at least 12-months' follow-up, in a French university hospital. Among the overall population of open or closed-globe emergencies (n = 40), non-penetrating corneal lamellar lacerations (long axis > 2 mm) in zone 1 (OTC group) were treated with V10-0 suture(s) (n = 10), replacing traditional non-absorbable 10-0 nylon suture(s) or medical options in first line. The outpatient visits were performed on day (D)10, month (M)2, M6 then every six months. One interim visit by phone teleconsultation was scheduled between D10 and M2, and other(s) as needed. The main outcome was best-corrected visual acuity (BCVA) at M6. Secondary outcomes included mainly corneal astigmatism (CA) at M6 complications. Results­Among the ten corneal wounds, there were three children (30%), eight domestic accidents (80%), three eyes with metallic foreign bodies (30%), four open-globe injuries (40%), and nine eyes that received high-speed projectiles or sharp objects (90%). The complete V10-0 suture(s) absorption occurred in all eyes between D10 and M2. At M6, mean far and near BCVA decreased from 0.680 ± 0.753 and 0.490 ± 0.338 preoperatively to 0.050 ± 0.071 and 0.220 ± 0.063 logMAR (p = 0.019 and p = 0.025 respectively), mean CA decreased from 4.82 ± 3.86 preoperatively to 1.15 ± 0.66 diopters (p = 0.008). BCVA and CA were unchanged thereafter. No serious adverse event nor repeated surgery occurred. The mean number of teleconsultations was 1.20 ± 0.63 without an additional nonscheduled outpatient visit. Conclusions­The absorbable V10-0 sutures might be a safe and effective alternative for eligible corneal wounds, while reducing the number of outpatient visits, especially for children (no suture removal). The COVID-19 pandemic highlighted that they are ideally suited to logistical challenges.

Epiretinal large disc of blue-stained lyophilized amniotic membrane to treat complex macular holes: a 1-year follow-up.

PURPOSE: To report the long-term outcomes of large diameter epiretinal lyophilized amniotic membranes (lAMs) in recurrent or persistent macular holes (MHs) with or without rhegmatogenous retinal detachment (RRD), in a prospective interventional case series. METHODS: Ten eyes of 10 patients underwent pars plana vitrectomy for MH-associated RRD (n = 5) or persistent MH without RRD (n = 5), in a university Hospital. A 3 or 4 mm diameter disc of lAM, stained with 0.06% trypan blue, was inserted with a catheter through a sclerotomy and positioned over the MH. Gas or silicone-oil tamponade was used. At 1 year, the main outcome was anatomic success defined as complete MH closure. Secondary outcomes were best corrected visual acuity (BCVA) recovery, changes in ellipsoid zone (EZ) and external limiting membrane (ELM) defects, complications. Mean follow-up was 13.8 ± 2.9 months (range, 12-18). RESULTS: Mean baseline data were minimum and maximum diameters, respectively, 945 ± 330 and 1507 ± 717 µm; axial length 26.58 ± 3.38 mm; and number of prior surgeries 1.4 ± 0.96. At 1 year, anatomic success was achieved in eight eyes (80%), and two had reduced diameter of MH. All RRDs were reattached without recurrence. Mean logMAR BCVA improved from 1.92 ± 0.58 to 1.17 ± 0.57 (p < 0.001), with nine eyes (90%) achieving ≥0.3 logMAR improvement. Mean EZ and ELM defects decreased (p = 0.004, p = 0.003, respectively). Postoperative complications were RRD (n = 1) reattached by subsequent surgery, lAM slightly retracted under silicone (n = 1), foveal atrophy after early lAM displacement (n = 1). CONCLUSION: A 1-year follow-up highlighted that epiretinal large discs of blue-stained lAM can help safely close refractory MHs, and provide satisfactory visual recovery.

Specular Microscopy of Human Corneas Stored in an Active Storage Machine.

PURPOSE: Unlike corneas stored in cold storage (CS) which remain transparent and thin, corneas stored in organoculture (OC) cannot be assessed by specular microscopy (SM), because edema and posterior folds occur during storage and prevent from specular reflection. We previously developed an active storage machine (ASM) which restores the intraocular pressure while renewing the storage medium, thus preventing major stromal edema. Its transparent windows allow multimodal corneal imaging in a closed system. AIM: to present SM of corneas stored in this ASM. METHODS: Ancillary study of two preclinical studies on corneas stored for one and three months in the ASM. A prototype non-contact SM was developed (CMOS camera, ×10 objective, collimated LED source, micrometric stage). Five non-overlapping fields (935 × 748 µm) were acquired in exactly the same areas at regular intervals. Image quality was graded according to defined categories (American Cornea Donor Study). The endothelial cell density (ECD) was measured with a center method. Finally, SMECD was also compared to Hoechst-stained cell nuclei count (HoechstECD). RESULTS: The 62 corneas remained thin during storage, allowing SM at all time points without corneal deconditioning. Image quality varied depending on donors and days of control but, overall, in the 1100 images, we observed 55% of excellent and 30% of good quality images. SMECD did not differ from HoechstECD (p = 0.084). CONCLUSIONS: The ASM combines the advantages of CS (closed system) and OC (long-term storage). Specular microscopy is possible at any time in the ASM with a large field of view, making endothelial controls easy and safe.

Characterization of Femtosecond Laser and Porcine Crystalline Lens Interactions by Optical Microscopy.

The use of ultrafast laser pulses for eye anterior segment surgery has seen a tremendous growth of interest as the technique has revolutionized the field, from the treatment of myopia, hyperopia, and presbyopia in the cornea to laser-assisted cataract surgery of the crystalline lens. For the latter, a comprehensive understanding of the laser-tissue interaction has yet to be achieved, mainly because of the challenge of observing the interaction zone in situ with sufficient spatial and temporal resolution in the complex and multi-layered tissue of the crystalline lens. We report here on the dedicated characterization results of the laser-tissue interaction zone in the ex vivo porcine lens using three different methods: in situ and real-time microscopy, wide-field optical imaging, and phase-contrast microscopy of the histological cross sections. These complementary approaches together revealed new physical and biological consequences of laser irradiation: a low-energy interaction regime (pulse energy below ~1 µJ) with very limited cavitation effects and a stronger photo-disruption regime (pulse energy above 1 µJ) with a long cavitation duration from seconds to minutes, resulting in elongated spots. These advances in the understanding of the ultrafast laser's interactions with the lens are of the utmost importance for the preparation of the next-generation treatments that will be applied to the lens.

Evaluation of the time required to complete a cataract training program on EyeSi surgical simulator during the first-year residency.

PURPOSE: To evaluate the time required to complete a cataract training program for first-year ophthalmology residents using the EyeSi simulator. In addition, evaluate whether the simulator improves virtual performance of cataract surgery during the program. METHODS: We prospectively included first-year ophthalmology residents who had no experience of cataract surgery. The EyeSi simulator was used, and residents were able to follow the cataract training program, including course A (the easiest) through to course D (the hardest). In course B and above, a "cataract challenge" is proposed to the trainee every hour of simulation. RESULTS: A total of 24 participants were included in the study. During the study period, the mean (SD) total time spent on the surgical simulator was 815.6 (174.7) minutes. All the participants completed courses A and B within a mean (SD) of 366.7 (108.0) minutes. A total of 22 residents (91.7%) residents completed course C, and 5 (20.8%) course D. The mean (SD) best score on cataract challenge was 445.6/500 (40.2; range: 330-493) and was obtained in a mean (SD) 7.6 (2.6) attempts. All the residents obtained a score ≥ 60%. The best score in cataract challenge was not correlated to the time spent to achieve courses A and B (r = -0.37, p = 0.0726). CONCLUSIONS: The time required to complete a basic cataract training program is possible during the first-year residency. The scores obtained in the cataract challenge also increased during the training program and should lead to better surgery skills in these young ophthalmologists.

Objective measurement of adherence to topical steroid medication after penetrating keratoplasty using an electronic monitoring aid: A pilot study.

Objectives: Corneal transplantation is the most common transplant worldwide and its success critically depends on the management of corneal graft rejection through topical steroid therapy during the first 12 months after surgery. There is currently no published data on adherence after keratoplasty. This pilot study aims to explore the adherence to topical steroid after penetrating keratoplasty using a smart electronic device. Methods: Thirty patients undergoing penetrating keratoplasty were included to evaluate the adherence to topical dexamethasone medication for 12 months after surgery. Patients received the usual post-transplantation treatment (topical dexamethasone) and follow-up after surgery (day 15, months 1, 2, 3, 4, 5, 6, 9, and 12). Adherence to treatment was monitored using the KaliJAR device (Kali Care, Santa Clara, CA, USA), which recorded the number of single-dose units (SDU) discarded. At control visits, data recorded by the device were compared to the manually count of SDU. Adherence ratio and individual adherence curve were explored for all patients. Results: Data from 27 patients showed a high agreement between adherence ratio calculated based on the device data and obtained from manual counting of the discarded SDU (intraclass coefficient correlation of 0.87 [95% CI: 0.738-0.938]). Mean adherence to the treatment over the 12-month study period was 95.2 ± 4%. Conclusions: Adherence to topical dexamethasone for 12 months after corneal transplantation was high. The connected device was able to record accurately the discarded SDU. This approach would be a particular interest in the early identification and personalized follow-up of poorly adherent patients.

Tolerance to Light of Patients Suffering From Infectious Keratitis.

PURPOSE: With very photophobic patients, the advantages of red or near infrared light to develop new ophthalmology imaging devices seem obvious: no or little glare, possibility of long signal integration, no phototoxicity, and lesser autofluorescence of ocular tissues. Nevertheless, in this range, the shortest possible wavelength facilitates signal detection. The aim of this study was, thus, to determine the maximal irradiance tolerated with 6 wavelengths: 2 red, 2 far red, and 1 near infrared lights to determine the shortest wavelength well tolerated by patients, in comparison with the standard cobalt blue light of ophthalmology slitlamp. METHODS: An interventional, monocentric, single-group assignment study was conducted on 30 eyes of 30 patients with infectious keratitis. Thanks to a customized machine, the photophobic eye was exposed to the 6 lights with increasing intensity. The patients switched off the light when the discomfort was too elevated. The maximal cumulative irradiance possible at 482, 650, 675, 700, 750, and 800 nm were 171, 689, 759, 862, 920, and 889 mW/cm, respectively. RESULTS: The maximal cumulative irradiance tolerated by patients increased significantly with wavelength (P < 0.001), but the difference was not significant between each increment: red at 675 nm gave a significantly higher cumulative irradiance than blue at 482 nm; red at 700 nm did not provide significant gain compared with 675 nm; and far red at 750 nm still provided additional gain compared with 700 nm, but no significant gain was observed between 750 and 800 nm. The shortest wavelengths were stopped more quickly, and more than 50% of patients reached the maximum irradiance delivered by the source at 750 and 800 nm. CONCLUSIONS: We demonstrate that a light source at 750 and 800 nm can be used for ophthalmic imaging with good tolerance in photophobic patients. CLINICAL TRIAL REGISTRATION: NCT03586505.

New Freeware for Image Analysis of Lissamine Green Conjunctival Staining.

PURPOSE: Lissamine green (LG) is often used in addition to fluorescein to assess the severity of conjunctival damage in dry eye syndrome, which is graded manually. Our purpose was to describe an algorithm designed for image analysis of LG conjunctival staining. METHODS: Twenty pictures of patients suffering from dry eye with visible LG conjunctival staining were selected. The images were taken by 2 different digital slit lamps with a white light source and a red filter transmitting over the wavelengths absorbed by LG. Conjunctival staining appeared in black on a red background. The red channel was extracted from the original image. Stained areas were then detected using a Laplacian of Gaussian filter and applying a threshold whose value was determined manually on a subset of images. The same algorithm parameters remained constant thereafter. LG-stained areas were also drawn manually by 2 experts as a reference. RESULTS: The delineation obtained by the algorithm closely matched the actual contours of the punctate dots. In 19 cases of 20 (95%), the algorithm found the same Oxford grade as the experts, even for confluent staining that was detected as a multitude of dots by the algorithm but not by the experts, resulting in a high overestimation of the total number of dots (without mismatching the Oxford grade estimated by the experts). The results were similar for the 2 slit-lamp imaging systems. CONCLUSIONS: This efficient new image-analysis algorithm yields results consistent with subjective grading and may offer advantages of automation and scalability in clinical trials.

Epithelial Regeneration in Human Corneas Preserved in an Active Storage Machine.

Purpose: To characterize the corneal epithelium (CE) and limbal epithelium (LE) of human corneas stored in an innovative active storage machine (ASM) after a period of organ culture (OC). Methods: Corneas unsuitable for graft and stored in a standard commercial OC medium for 2 to 5 weeks were transferred into our ASM for 14 days. The ASM actively maintained an overpressure on the endothelial side (20 mm Hg) while ensuring medium renewal. We compared three modalities of storage in the ASM's epithelial chamber: (1) alternating exposure to a supplemental hormonal epithelial medium (SHEM) and air (air-lifting), (2) continuous immersion in SHEM, and (3) continuous immersion in OC medium. Passive immersion of the whole cornea in OC medium or of the CE in SHEM with or without airlifting served as controls. Paired corneas were used for better comparability. Histology, differentiation (by immunolabeling), and ultrastructure were analyzed at the end. Results: The ASM with air-lifting was most effective in regenerating a pluristratified and differentiated CE (apical ZO-1 and MUC16 staining and regeneration of the glycocalyx). In addition, the LE was stratified with preserved expression of ABCB5. The ASM with immersion in SHEM or OC medium gave a less stratified and differentiated CE. In the three control groups, the epithelia, when present, were paucistratified and less differentiated. Conclusions: In human corneas previously stored in OC, the ASM regenerates a CE with differentiation characteristics close to normal. Translational Relevance: Regeneration of the epithelium of human corneas discarded by eye banks will increase tissue availability for research.