Clinical Manifestations and Long-term Outcomes of Endothelial Keratoplasty in Patients with Proven VZV-related Endothelial Decompensation.

PURPOSE: To report the clinical manifestations, postoperative complications and long-term outcomes of endothelial keratoplasty in VZV-related endothelial decompensation. METHODS: In this retrospective study, thirteen eyes undergoing endothelial keratoplasty (EK) for VZV-related endothelial decompensation were compared with controls for Fuchs endothelial dystrophy or pseudophakic bullous keratopathy. RESULTS: Twelve patients did not have typical dermal pain or blisters. Ten patients had obvious iris abnormalities. Glaucoma was noted in eight patients before surgery. The best spectacle-corrected visual acuity improved from 1.12 ± 0.47 to 0.39 ± 0.43 (p = .002), whereas endothelial cell (EC) loss was 65% ±15% at 12 months that higher than that in the controls (p < .05). Postoperative complications included graft detachment (2/13), recurrence of endotheliitis (3/13), neurotrophic ulcer (1/13) and scleritis (1/13). CONCLUSIONS: The onset of VZV-related endothelial decompensation is generally insidious. Iris segmental atrophy, glaucoma and pigment KPs are highly suspected to be associated with VZV. EK is a reasonable option to rehabilitate vision.

Tear Cytokines as Biomarkers for Acute Ocular Graft-Versus-Host Disease.

PURPOSE: The purpose of this study was to analyze tear cytokine and complement levels in patients diagnosed with acute ocular graft-versus-host disease (oGVHD) and examine the consistency of these levels with the severity of clinical manifestations. METHODS: Ten patients with acute oGVHD (20 eyes) were enrolled for the assessment of tear cytokine levels and ocular surface parameters, and 18 healthy people (36 eyes) were selected as the control group. The tear cytokine and complement levels were measured using microsphere-based immunoassay analysis. RESULTS: The main clinical manifestations of acute oGVHD include eye redness, a large amount of purulent exudate, eye pain, and even false membranes. The levels of intercellular cell adhesion molecule-1, interleukin 6 (IL-6), interleukin 1 beta (IL-1ß), interleukin 8, epidermal growth factor (EGF), interleukin 7 (IL-7), B-cell activating factor, granulocyte-macrophage colony-stimulating factor (GM-CSF), and complement in patients with acute oGVHD showed significant differences compared with those in normal people. Furthermore, the levels of IL-6, IL-1ß, EGF, GM-CSF, IL-7, and C3a showed a stronger correlation with ocular surface parameters. CONCLUSIONS: Our study was the first to enroll patients with acute oGVHD to assess tear cytokine levels as a method contributing to the diagnosis of acute oGVHD. In addition, it has been demonstrated that certain tear cytokines, including intercellular cell adhesion molecule-1, IL-6, IL-1ß, interleukin 8, B-cell activating factor, GM-CSF, IL-7, EGF, and complement, may be new diagnostic biomarkers for acute oGVHD.

Pathogenic Effects and Pathogenesis Processes in Vitro & in Vivo in Murine Cytomegalovirus Infected Rat Corneal Endothelial Cells.

PURPOSES: To understand the pathogenesis in rat corneal endothelial cells (RCECs) induced by murine cytomegalovirus infection in vitro and in vivo. METHODS: In vitro, cultured RCECs were infected with murine cytomegalovirus strain K181-eGFP (MCMV-eGFP). In vivo, experimental rats received intracameral injection of MCMV-eGFP. Replicating viruses and morphology change of RCECs in vivo were evaluated at several time points. RESULTS: In vitro, RCECs became necrosis at 6hpi. MCMV-eGFP began replicating at 12hpi. In vivo, the inflammatory reactions appeared at 12hpi, peaked at 72hpi and gradually subsided. Replicating MCMV-eGFP appeared in RCECs in vivo from 24hpi to 72hpi. RCECs enlarged after 12hpi and capsids in the nuclei were visible at 72hpi. A monocyte was found on a corneal endothelium at 120hpi. CONCLUSIONS: RCECs were sensitive to MCMV in vitro. Replication of MCMV-eGFP in vivo began at 24hpi and ended after 72hpi, later than the inflammatory reactions.

Loss of endothelial cells in viral DNA-positive grafts after keratoplasty: a 2-year follow-up study.

BACKGROUND: To compare endothelial loss between recipients who received viral DNA-positive grafts and controls 2 years after corneal transplantation. METHODS: We retrospectively analysed the clinical data and endothelial cell density of recipients of viral DNA-positive grafts and age-, sex-, aetiology- and operation-matched controls from April 2017 to July 2019 at the Peking University Third Hospital, Beijing, China. RESULTS: A total of 23/942 (2.44%) donor corneal buttons tested virus-positive by real-time PCR. A total of 27 recipients (except for 2 recipients) of viral DNA-positive grafts and 48 recipients of viral DNA-negative grafts were included in this study. Recipients of viral DNA-positive grafts had a higher endothelial cell (EC) loss rate post-penetrating keratoplasty and post-descemet stripping automated endothelial keratoplasty (p<0.05), but post-deep lamellar keratoplasty, the EC loss rate was similar to that of the controls. Recipients of herpes simplex virus-1-, cytomegalovirus- and varicella-zoster virus-positive grafts all had a higher EC loss rate than the controls during the 12- and 24-month follow-up periods (p<0.05). CONCLUSION: We inferred that viruses might be hidden in corneal grafts and mainly incubate in the corneal endothelium. Viral DNA-positive grafts do not need to be replaced immediately and can be followed up for a long time.

Characteristics of Corneal Endotheliitis among Different Viruses by in Vivo Confocal Microscopy.

Objectives: To explore the cellular morphological characteristics and changes in corneal endotheliitis among different viruses by in vivo confocal microscopy (IVCM).Methods: Corneal confocal images of 44 eyes of 44 patients with HSV, VZV, CMV and EBV corneal endotheliitis were studied retrospectively. Corneal confocal images of 44 normal eyes were used as controls.Results: The pathogens included cytomegalovirus (n = 20), herpes simplex virus (n = 8), varicella zoster virus (n = 10), and Epstein Barr virus (n = 6). There were no differences in the evaluated structures among the different viruses except for the lengths of the subbasal nerves and Langerhans cell densities. Deviations in endothelial cell layers were not significant among different viruses except for owl's eye morphology.Conclusion: ICVM can assist in diagnosing endotheliitis. The results demonstrate that changes in the cornea were not different among the various viruses except for owl's eye morphology, the lengths of the subbasal nerves and Langerhans cell densities.

The incidence and influence of the donor corneas positive for herpesviridae DNA in keratoplasty.

PURPOSE: We detected the DNA of herpes simplex virus type 1 (HSV-1), herpes simplex virus type 2 (HSV-2), varicella-zoster virus (VZV), cytomegalovirus (CMV), and Epstein-Barr virus (EBV) in donor corneas and assessed the clinical outcomes of recipients who received virus-positive grafts. METHOD: All donor corneas were analyzed for the presence of HSV-1, HSV-2, VZV, CMV, and EBV by real-time PCR from April 2017 to July 2019. The medical records of the transplant patients who received virus-positive grafts were reviewed. RESULT: Twenty-three (2.44%) donor cornea buttons tested positive for herpesviridae DNA. The positivity rates of HSV-1, CMV, VZV, and EBV were 0.74%, 0.85%, 0.64%, and 0.21%, respectively. CONCLUSION: We suggest that the corneas from donors who had cancer, donors who were inpatients, and donors who had immunodeficiency or who were on immunosuppressive therapy should be tested for herpesviridae DNA before transplantation. Finally, HSV-1 can be transmitted from graft to recipient, but that CMV cannot be transmitted according to our observations. The donor corneas found to be HSV-1-positive have to be discarded and not used for keratoplasty.

Evaluation of reconstructed human corneal endothelium sheets made with porcine Descemet's membrane in vitro and in vivo.

PURPOSE: To identify the feasibility of reconstructing corneal endothelial sheets by seeding non-infected monoclonal human corneal endothelial cells (HCECs) onto porcine Descemet's membrane (DM) and verifying the function in vitro and in vivo. METHODS: Denuded porcine DM was decellularized for haematoxylin and eosin staining, and DNA was removed via incubation with ethylene glycol diglycidyl ether (EGDE). The physical properties of the incubated DMs were evaluated and compared to those of unincubated DMs. The non-infected monoclonal HCECs were examined by chromosome analysis and the cell proliferation was evaluated by BrdU-labelling. Then HCECs at passage 30 were then seeded on the DM and cultured for approximately 5 days. The cell growth, density and expression of the sodium-potassium adenosine triphosphatase (Na+/K+-ATPase), the tight-junction-associated protein zonula occludens (ZO-1) and acetylated alpha tubulin were examined by electron microscopy and immunocytochemistry to compare HCECs cultivated on porcine DM and those cultured in vitro. Cells on the reconstructed HCEC sheets were labeled with DiI, and the sheets were subsequently transplanted into cat eyes via DM endothelial keratoplasty (DMEK). The corneal transparency, thickness, anterior segment, and HCEC density were monitored in vivo, and the corneal endothelial cell morphology and histological structure were examined ex vivo 98 days after surgery. RESULTS: No significant differences were observed in the elongation at break of the DMs and the thickness of the DMs incubated with EGDE compared to those of the unincubated DMs (P > 0.05). Results of chromosome analysis shown the number of the HCEC cell line was still 46 and no abnormal chromosome structure was found. BrdU-labelling shown the HCECs stopped proliferating after 5 days and the cells formed a single layer. The cells transferred to porcine DM formed tight connections with the substrate and generated layers of hexagonal cells on day 5. Adjacent cells cultivated on DM were closely attached to each other, tightly adhered to the porcine DM and expressed the Na+/K+-ATPase, ZO-1 protein and acetylated alpha tubulin, as did HCECs cultured in vitro. In addition, the HCEC density on DMs was 3020.14 ± 52.30 cells/mm2. After surgery, the corneas gradually became transparent, and the thickness decreased to 525.33 ± 56.23 µm at day 98 after the transplantation, while the control corneas showed consistent oedema during the monitoring period. The HCEC density was 2521.60 ± 78.24 cells/mm2 in vivo 98 days after transplantation. The histological results showed that the DiI-labeled cells were dense in the transplanted area and had a hexagonal or polygonal morphology and a normal ultrastructure; adjacent cells were closely attached to each other and tightly adhered to the porcine DM. CONCLUSIONS: Seeding non-infected monoclonal HCECs on porcine DM could reconstruct functional corneal endothelial sheets. These results may help uncover new applications for tissue-engineered endothelium in endothelial keratoplasty.

Clinical consequences of herpes simplex virus DNA in donor corneas: Different prognosis and management of endothelial keratoplasty and deep anterior lamellar keratoplasty.

BACKGROUND: There is still controversy over the necessity of screening donor corneas for herpes simplex virus (HSV). Currently, no study reported the outcomes of different types of keratoplasty with HSV-positive donor corneas. OBJECTIVES: To describe the clinical consequences of four patients who underwent keratoplasty by sharing double corneas from a single donor, both of which were positive for HSV-1 DNA by polymerase chain reaction. STUDY DESIGN: A retrospective case series study. RESULTS: Both patients who underwent endothelial keratoplasty (EK) developed persistent corneal edema with or without keratic precipitates, and mild anterior chamber inflammation on postoperative day 3 and 17 respectively. Despite adequate antiviral treatment, they developed graft detachment subsequently and experienced graft replacement. Transmission electron microscopy showed denuded Descemet's membrane without any endothelial cells on both removed grafts and viral particles were identified within the residual posterior stroma of the thicker graft. As for those who underwent deep anterior lamellar keratoplasty, one patient presented with graft rejection for the sake of self-discontinuation of all anti-rejection agents. The other's graft remained clear at the final follow-up. CONCLUSIONS: HSV existed in the posterior stromal and endothelial layer of the donor corneas. Reactivation of HSV and severe endothelial loss may occur on corneal endothelial grafts in the early postoperative period while anterior lamellar grafts could be quiescent. Considering the possibility of graft failure caused by viral reactivation, it's of great significance to screen for viral DNA in donor corneas prior to the surgery, especially for EK.

Mertk gene expression and photoreceptor outer segment phagocytosis by cultured rat bone marrow mesenchymal stem cells.

BACKGROUND: Bone marrow mesenchymal stem cells (BM-MSCs) are multipotential stem cells that have been used for a broad spectrum of indications. Several investigations have used BM-MSCs to promote photoreceptor survival and suggested that BM-MSCs are a potential source of cell replacement therapy for some forms of retinal degeneration. PURPOSE: To investigate the expression of the MER proto-oncogene, tyrosine kinase (Mertk), involved in the disruption of RPE phagocytosis and the onset of autosomal recessive retinitis pigmentosa in rat BM-MSCs and to compare phagocytosis of the photoreceptor outer segment (POS) by BM-MSCs and RPE cells in vitro. METHODS: MSCs were isolated from the bone marrow of Brown Norway rats. Reverse transcription-PCR (RT-PCR) and western blot analyses were used to examine the expression of Mertk. The phagocytized POS was detected with double fluorescent labeling, transmission electron microscopy, and scanning electron microscopy. RESULTS: Mertk expression did not differ among the first three passages of BM-MSCs. Mertk gene expression was greater in the BM-MSCs than the RPE cells. Mertk protein expression in the BM-MSCs was similar to that in the RPE cells in the primary passage and was greater than that in the RPE cells in the other two passages. BM-MSCs at the first three passages phagocytized the POS more strongly than the RPE cells. The process of BM-MSC phagocytosis was similar to that of the RPE cells. CONCLUSIONS: BM-MSCs may be an effective cell source for treating retinal degeneration in terms of phagocytosis of the POS.

Suture pull-through insertion techniques for Descemet stripping automated endothelial keratoplasty in Chinese phakic eyes: outcomes and complications.

PURPOSE: To investigate the outcomes and complications of suture pull-through insertion techniques for Descemet stripping automated endothelial keratoplasty (DSAEK) in Chinese phakic eyes. PATIENTS AND METHODS: Retrospective case series. Included in the study were all Chinese patients with phakic eyes who underwent DSAEK at Peking University Third Hospital from August 2008 to August 2011. All ocular diseases of the patients were recorded. Distance visual acuity (DVA), near visual acuity (NVA), intraocular pressure (IOP), anterior chamber depth (ACD), central corneal thickness (CCT), and corneal endothelial cell density (ECD) were compared prior to and 12 months after DSAEK. The DSAEK success rate, endothelial cell loss (ECL), complications, and prognosis were analyzed. All patients had at least 12 months of follow up. RESULTS: Twenty-one eyes of 16 patients were included (11 males and 5 females). Ages ranged from 2 to 47 years with an average age of 29.8 years. The average follow up was 15.4 months (ranging from 12 to 36 months). Diagnoses included 7 eyes (4 patients) with corneal endothelial dystrophy and 14 eyes (12 patients) with bullous keratopathy. Presurgical DVA and NVA (LogMAR) were 1.7 ± 0.7 and 1.2 ± 0.4; postsurgical DVA and NVA were 0.8 ± 0.6 and 0.7 ± 0.5; Z = -3.517, -2.764; P<0.001 and P = 0.006 respectively. Presurgical IOP was 15.8 ± 3.7 mm Hg; postsurgical IOP was 15.2 ± 2.6 mm Hg; Z = -0.505, P = 0.614. Presurgical ACD was 3.00 ± 0.74 mm; postsurgical ACD was 2.72 ± 0.59 mm; Z = -0.524, P = 0.600. Donor ECD was 2992 ± 163 cells/mm(2), ECD was 1836 ± 412 cells/mm(2) with a 12-month postsurgical ECL of 39%. Success rate was 86%. Surgery complications included pupillary block-induced hypertension in 5 eyes (24%), graft detachment in 3 eyes (14%), and graft dislocation in 1 eye (5%). CONCLUSIONS: DSAEK on Chinese phakic eyes can significantly improve DVA and NVA by preserving the patient's own crystalline lens. DSAEK is an optional surgery for patients who need to preserve accommodative function. More attention should be given to postsurgical pupillary block-induced hypertension.

[The effect of descemet-stripping automated endothelial keratoplasty combined with phacoemulsification cataract surgery or lens exchange].

OBJECTIVE: To evaluate the effect and explore the complications of Descemet-stripping automated endothelial keratoplasty (DSAEK) combined with phacoemulsification cataract surgery or lens exchange in corneal endothelial dysfunction eyes with lens disorders. METHODS: Retrospective case series. Eighteen consecutive cases (20 eyes) were performed DSAEK combined with lens surgery from December 2007 to December 2008 in Department of Ophthalmology, Peking University Third Hospital. Five cases (7 eyes) were performed DSAEK combined with phacoemulsification and intraocular lens (IOL) insertion. Seven cases were combined with anterior chamber IOL extraction, anterior vitrectomy and posterior chamber IOL insertion. Six aphakia cases were performed with DSAEK combined with anterior vitrectomy and sclera fixation posterior chamber IOL insertion. Postoperatively, the visual acuity, corneal transparency, central corneal thickness (CCT), endothelial cell density (ECD) and complications were observed during the follow-up. RESULTS: The irritation was disappeared in all of patients. All of the corneas became transparent. The preoperative and postoperative mean CCT of the recipient beds was 859 µm and 553 µm respectively. T value was 5.303 (t = 5.303, P < 0.01). It was extremely significant difference. The mean ECD of the donors was 2987 cells/mm(2). The ECD was 1803 cells/mm(2) in three months postoperatively. The rate of endothelial cells loss was 41%. The visual acuity improved significantly except 9 eyes which had fundus disorders. Six eyes were better than 0.8. It was 55% in normal retinal function patients (6/11). The inflammatory reaction of the anterior chamber IOL eyes was most serious. Six eyes underwent graft dislocation. Five cases underwent high intraocular pressure. One case occurred graft rejection. These complications occurred in anterior chamber IOL eyes. CONCLUSIONS: DSAEK combined with phacoemulsification cataract surgery or lens exchange is a safe and effective surgical treatment for corneal endothelial dysfunction with lens disorders. More complications occur in anterior chamber IOL eyes. DSAEK should be cautiously chosen in abnormal iris and chamber angle structural eyes.

Endothelial keratoplasty: the use of viscoelastic as an aid in reattaching the dislocated graft in abnormally structured eyes.

PURPOSE: To explore the feasibility of reattaching the dislocated graft with viscoelastic in abnormally structured eyes after Descemet-stripping automated endothelial keratoplasty (DSAEK). DESIGN: Retrospective case series. PARTICIPANTS: Five pseudophakic bullous keratopathy cases (5 eyes) with a history of vitrectomy and/or iris-lens diaphragm injury. METHODS: After DSAEK, graft dislocation occurred in each of the 5 cases (5 eyes). We attempted to fill the anterior chamber (AC) with an air bubble to push up the dislocated graft, but this was not successful. We then injected balanced salt solution into the vitreous body to obtain normal intraocular pressure (IOP) and injected a small amount of viscoelastic (Healon GV) to support the AC. Next, we injected an air bubble into the AC. MAIN OUTCOME MEASURES: The position of the grafts was checked with a slit lamp and anterior segment optical coherence tomography (AS-OCT). The IOP was observed with Goldmann tonometer. The best visual acuity was checked. RESULTS: As observed through the slit lamp and AS-OCT, the grafts reattached well in all patients. The IOP was normal in all patients except one, who had high IOP 1 month postoperatively. After receiving drug treatment, the patient's IOP returned to normal. The grafts had slight edema on postoperative day 1, but became transparent between days 5 and 8. CONCLUSIONS: Viscoelastic aided in the reattachment of the dislocated graft in eyes with a history of vitrectomy and/or iris-lens diaphragm injury. The presence of viscoelastic in the AC in the early period of post-DSAEK was well tolerated in this small series.