Tissue-derived microparticles reduce inflammation and fibrosis in cornea wounds.

Biological materials derived from the extracellular matrix (ECM) of tissues serve as scaffolds for rebuilding tissues and for improved wound healing. Cornea trauma represents a wound healing challenge as the default repair pathway can result in fibrosis and scar formation that limit vision. Effective treatments are needed to reduce inflammation, promote tissue repair, and retain the tissue's native transparency and vision capacity. Tissue microparticles derived from cornea, cartilage and lymph nodes were processed and screened in vitro for their ability to reduce inflammation in ocular surface cells isolated from the cornea stroma, conjunctiva, and lacrimal gland. Addition of ECM particles to the media reduced expression of inflammatory genes and restored certain tear film protein production in vitro. Particles derived from lymph nodes were then applied to a rabbit lamellar keratectomy corneal injury model. Application of the tissue particles in a fibrin glue carrier decreased expression of inflammatory and fibrotic genes and scar formation as measured through imaging, histology and immunohistochemistry. In sum, immunomodulatory tissue microparticles may provide a new therapeutic tool for reducing inflammation in the cornea and ocular surface and promoting tissue repair. STATEMENT OF SIGNIFICANCE: Damaged cornea will result in scar tissue formation that impedes vision, and new therapies are needed to enhance wound healing in the cornea and to prevent fibrosis. We evaluated the effects of biological scaffolds derived extracellular matrix (ECM) during corneal wound healing. These ECM particles reduced inflammatory gene expression and restored tear film production in vitro, and reduced scar formation and fibrosis genes in the wounded cornea, when applied to in vivo lamellar keratectomy injury model. The immunomodulatory tissue microparticles may provide a new therapeutic tool for reducing inflammation in the cornea and ocular surface and promoting proper tissue repair.

Factors Associated With Graft Rejection in the Cornea Preservation Time Study.

PURPOSE: To identify factors related to graft rejection following Descemet stripping automated endothelial keratoplasty (DSAEK) in the Cornea Preservation Time Study (CPTS). DESIGN: Cohort study within a multicenter randomized clinical trial. METHODS: A total of 1330 eyes of 1090 subjects undergoing DSAEK were randomized to receive a donor cornea with preservation time (PT) of 0-7 days (n = 675) or 8-14 days (n = 655) and followed for 3 years. Central endothelial cell density (ECD) was determined by a central image analysis reading center. Multivariable Cox models adjusted for PT, recipient diagnosis, and surgeon effect were used to identify factors associated with rejection. RESULTS: Cumulative probability of definite graft rejection was 3.6% (99% confidence interval 2.5%-5.3%). Younger recipient age was associated with graft rejection (P < .001; hazard ratio: 0.53 [0.33, 0.83] per decade). PT, donor-recipient sex mismatch, recipient diagnosis, recipient race, graft size, discontinuation of topical corticosteroids and immune-modulators, prior immunizations within 3 months, and prior glaucoma surgery were not associated with rejection (P > .01). Among clear grafts with an ECD measurement at baseline and 3 years (n = 913), endothelial cell loss (ECL) was greater in eyes that experienced a rejection episode (n = 27) than in those that did not (n = 886) (48% vs 38%, P = .03). Twelve of 44 eyes (27%) with definite graft rejection subsequently failed, comprising 15% of the 79 failures in the CPTS. CONCLUSIONS: Graft rejection is uncommon after DSAEK and more likely with younger age, in a study cohort mostly > 50 years old. Rejection increases ECL, but it is not a leading cause of DSAEK failure.

Longitudinal Study of Age-Related Cataract Using Dynamic Light Scattering: Loss of α-Crystallin Leads to Nuclear Cataract Development.

PURPOSE: To conduct a longitudinal study on age-related nuclear cataracts using dynamic light scattering (DLS) to determine if cataract progression is associated with loss of the unbound form of the lens molecular chaperone protein, α-crystallin. DESIGN: Natural history and cohort study. PARTICIPANTS: Patients 30 years of age or older of either gender seeking treatment at the Wilmer Eye Institute Cornea-Cataract Department. METHODS: All patients underwent a comprehensive dilated eye examination every 6 months, including slit-lamp grading of their lenses using the Age-Related Eye Disease Study (AREDS) clinical lens grading system and obtaining an estimate of unbound α-crystallin level in the nucleus, the α-crystallin index (ACI), using the National Aeronautics and Space Administration-National Eye Institute DLS device. We used a random effects statistical model to examine the relationship of lens opacity changes over time with ACI changes. MAIN OUTCOME MEASURES: α-Crystallin Index (ACI) and AREDS nuclear cataract grade. RESULTS: Forty-five patients (66 eyes) 34 to 79 years of age with AREDS nuclear lens grades of 0 to 3.0 were followed up every 6 months for a mean of 19 months (range, 6-36 months). We found that lenses with the lowest baseline levels of ACI had the most rapid progression of cataracts, whereas lenses with higher ACI at baseline had no or slower cataract progression. Lenses that lost α-crystallin at the highest rates during the study also had faster progression of nuclear cataracts than lenses with a slower rate of ACI loss. Kaplan-Meier survival curves showed that lenses with the lowest initial ACI had the highest risk of undergoing cataract surgery. CONCLUSIONS: This longitudinal study corroborates our previous cross-sectional study finding that higher levels of unbound α-crystallin as assessed by ACI are associated with lower risk of cataract formation and that loss of ACI over time is associated with cataract formation and progression. This study suggested that assessment of ACI with the DLS device could be used as a surrogate for lens opacity risk in clinical studies, and for assessing nuclear cataract events in studies where cataract development may be a side effect of a drug or device.

Report of a 10-0 polypropylene suture that did not undergo biodegradation after 13 years in the eye.

We report the case of a 70-year-old man who underwent surgery to fixate a subluxated intraocular lens. A 10-0 polypropylene suture that had been placed 13 years prior was retrieved intraoperatively and subsequently imaged using electron microscopy. The suture showed no clinically significant signs of biodegradation.

Pars plana vitrectomy and iris suture fixation of posteriorly dislocated intraocular lenses.

PURPOSE: To describe the outcomes of combined pars plana vitrectomy (PPV) and iris suture fixation of posteriorly dislocated intraocular lenses (IOLs). SETTING: Tertiary academic referral center. DESIGN: Retrospective noncomparative consecutive case series. METHODS: The included eyes had posteriorly dislocated IOLs and had combined PPV and iris suture fixation. The IOL dislocations amenable to surgical repair with an anterior approach were excluded. Outcome measures included improvement in corrected distance visual acuity (CDVA), induction of astigmatism, and complications. RESULTS: This study consisted of 27 consecutive cases. The mean follow-up was 6.61 months ± 8.1 (SD). The median postoperative CDVA was 20/30, and 16 of 27 eyes had stable or improved CDVA compared with baseline; 8 of the others had a shift from aphakic to pseudophakic correction. Overall, a significant myopic shift in spherical equivalent occurred after surgery, from 7.62 ± 4.38 diopters (D) to -1.33 ± 1.45 D (P < .001). Surgically induced astigmatism (SIA) assessed by comparing the difference in preoperative keratometry readings with the difference in postoperative manifest refraction cylinder adjusted to the corneal plane gave the following: 1.89 ± 1.09 D versus 1.13 ± 0.86 D, respectively (P < .001). All IOLs were stable and centered at the last follow-up; however, 1 was mildly tilted. One eye had a recurrent subluxation, and the IOL was resutured before the end of the study. No cases of endophthalmitis or retinal detachment occurred. CONCLUSION: Combined PPV and iris suture fixation of posteriorly dislocated IOLs led to stable fixation of the IOLs. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Outcomes Associated With Concurrent Iris-Sutured Intraocular Lens Placement and Subluxated Crystalline Lens Extraction.

IMPORTANCE: We have developed a novel surgical technique, to our knowledge, for the management of subluxated crystalline lenses involving preplacement of an iris-sutured posterior chamber intraocular lens (PCIOL) before pars plana vitrectomy and lensectomy. OBJECTIVE: To investigate the outcomes of eyes with subluxated crystalline lenses, predominantly a result of Marfan syndrome (14 eyes [58%]) or trauma (5 eyes [21%]), that underwent pars plana vitrectomy and lensectomy with placement of an iris-sutured PCIOL. DESIGN, SETTING, AND PARTICIPANTS: We performed a retrospective, noncomparative case series of 24 eyes from 17 consecutive adult patients with surgically treated subluxated crystalline lenses presenting to the Wilmer Eye Institute at Johns Hopkins Hospital from October 6, 2006, through May 1, 2013. The mean (SD) postoperative follow-up was 24.4 (20.5) months for eyes with at least 6 months of follow-up (last date, October 13, 2014). We performed the analysis from January 21, 2014, through January 3, 2015. MAIN OUTCOMES AND MEASURES: Improvement in best-corrected visual acuity using an automated Snellen chart and induction of astigmatism for eyes with at least 6 months of follow-up (n = 18) and IOL stability during follow-up for all eyes (n = 24). RESULTS: The mean (SD) age at surgery was 49.4 (10.7 [range, 29-67]) years. We found an improvement in mean (SD [95% CI]) best-corrected visual acuity from 0.66 (0.71 [0.30-1.02]) logMAR preoperatively (Snellen equivalent, approximately 20/90; range, 20/30 to hand motions) to 0.07 (0.11 [95% CI, 0.01-0.12]) logMAR postoperatively (Snellen equivalent, approximately 20/23; range, 20/15 to 20/50). We found little change in astigmatism postoperatively (mean change, -0.1 [95% CI, -0.5 to 0.13] diopters). Postoperative complications included retinal detachment (1 eye [4%]), retained cortical fragment (1 [4%]), cystoid macular edema (2 [8%]), and IOL subluxation (3 [13%]) owing to haptic slippage within 3 months of the procedure. The overall probability of successfully achieving placement of a centered iris-sutured PCIOL in patients with follow-up of longer than 6 months (n = 18) was 100% (95% CI, 81.5%-100%). CONCLUSIONS AND RELEVANCE: Placement of iris-sutured PCIOLs at the time of subluxated lens extraction with a pars plana surgical approach yields favorable results in terms of postoperative visual outcomes and surgical complications. This technique offers an effective procedure for surgeons to use when treating clinically significant subluxated crystalline lenses.

Corticosteroid-loaded biodegradable nanoparticles for prevention of corneal allograft rejection in rats.

Immunologic graft rejection is one of the main causes of short and long-term graft failure in corneal transplantation. Steroids are the most commonly used immunosuppressive agents for postoperative management and prevention of corneal graft rejection. However, steroids delivered in eye drops are rapidly cleared from the surface of the eye, so the required frequency of dosing for corneal graft rejection management can be as high as once every 2h. Additionally, these eye drops are often prescribed for daily use for 1 year or longer, which can result in poor patient compliance and steroid-related side effects. Here, we report a biodegradable nanoparticle system composed of Generally Regarded as Safe (GRAS) materials that can provide sustained release of corticosteroids to prevent corneal graft rejection following subconjunctival injection provided initially during transplant surgery. Poly(lactic-co-glycolic acid) (PLGA) nanoparticles containing dexamethasone sodium phosphate (DSP) exhibited a size of 200 nm, 8 wt.% drug loading, and sustained drug release over 15 days in vitro under sink conditions. DSP-loaded nanoparticles provided sustained ocular drug levels for at least 7 days after subconjunctival administration in rats, and prevented corneal allograft rejection over the entire 9-week study when administered weekly. In contrast, control treatment groups that received weekly injections of either placebo nanoparticles, saline, or DSP in solution demonstrated corneal graft rejection accompanied by severe corneal edema, neovascularization and opacity that occurred in ≤ 4 weeks. Local controlled release of corticosteroids may reduce the rate of corneal graft rejection, perhaps especially in the days immediately following surgery when risk of rejection is highest and when typical steroid eye drop administration requirements are particularly onerous.

Iris suture fixation of subluxated intraocular lenses.

PURPOSE: To assess the results of iris suture fixation of subluxated intraocular lenses. DESIGN: Retrospective study. METHODS: This was a nonrandomized chart review of eyes with subluxated intraocular lenses that underwent iris suture fixation at an academic institutional care center. Seventy-two eyes of 67 consecutive patients were included. The following cases were excluded: posterior dislocations necessitating pars plana vitrectomy; secondary implantations for aphakia; and iris suture fixation at primary cataract extraction. Main outcome measures included visual acuity improvement, surgically induced astigmatism, and postsurgical complications. RESULTS: The mean follow-up duration was 16.64 ± 24.37 months (median = 4.03 months). All patients had preoperative monocular diplopia or unstable vision attributable to the subluxated intraocular lenses, and 40.3% of them required aphakic correction. There was an overall improvement in best-corrected visual acuity from a mean preoperative logMAR 0.35 ± 0.32 (Snellen equivalent∼20/45) to logMAR 0.21 ± 0.25 (20/32, P = .001). There was no significant change in astigmatism secondary to the surgery. The mean difference in preoperative keratometry readings was 1.6 ± 1.07 diopter (D), whereas the mean postoperative manifest refraction astigmatic error (vertexed to the corneal surface) was 1.29 ± 0.92 D (P < .02). Re-subluxations occurred in 7 eyes during follow-up; the majority of these eyes underwent repeat fixation. Most (93.55%) intraocular lenses were stable and centered at the final follow-up. Glaucoma developed in 2 eyes postoperatively. CONCLUSIONS: Iris suture fixation of subluxated intraocular lenses was efficacious for the eyes included in this study, and it led to long-term stability of the intraocular lenses in 93.55% of cases.

Corneal graft rejection 10 years after penetrating keratoplasty in the cornea donor study.

PURPOSE: The aim of this study was to assess the effect of donor and recipient factors on corneal allograft rejection and evaluate whether a rejection event was associated with graft failure. METHODS: One thousand ninety subjects undergoing penetrating keratoplasty for a moderate risk condition (principally Fuchs dystrophy or pseudophakic corneal edema) were followed for up to 12 years. Associations of baseline recipient and donor factors with the occurrence of a rejection event were assessed in univariate and multivariate proportional hazards models. RESULTS: Among 651 eyes with a surviving graft at 5 years, the 10-year graft failure (±99% confidence interval) rates were 12% ± 4% among eyes with no rejection events in the first 5 years, 17% ± 12% in eyes with at least 1 probable, but no definite rejection event, and 22% ± 20% in eyes with at least 1 definite rejection event. The only baseline factor significantly associated with a higher risk of definite graft rejection was a preoperative history of glaucoma, particularly when previous glaucoma surgery had been performed and glaucoma medications were being used at the time of transplant (10-year incidence 35% ± 23% compared with 14% ± 4% in eyes with no history of glaucoma/intraocular pressure treatment, P = 0.008). CONCLUSIONS: Patients who experienced a definite rejection event frequently developed graft failure raising important questions as to how we might change acute and long-term corneal graft management. Multivariate analysis indicated that previous use of glaucoma medications and glaucoma filtering surgery was a significant risk factor related to a definite rejection event.

Refractive surgery in systemic and autoimmune disease.

Patients with underlying systemic disease represent challenging treatment dilemma to the refractive surgeon. The refractive error in this patient population is accompanied by a systemic disease that may have an ocular or even a corneal component. The literature is rather sparse about the use of laser refractive surgery (LRS) and such procedure is not approved by the United States Food and Drug Administration (FDA) in this patient population. Patients with collagen vascular disease, diabetes mellitus (DM), allergic and atopic disease, or human immunodeficiency virus (HIV) are never ideal for LRS. Patients with uncontrolled systemic disease or ocular involvement of the disease should not undergo LRS. However, a patient with well-controlled and mild disease, no ocular involvement, and not on multidrug regimen may be a suitable candidate if they meet stringent criteria. There is a need for a large, multicenter, controlled trial to address the safety and efficacy of LRS in patients with systemic disease before such technology can be widely adopted by the refractive surgery community.

Autologous serum eye drops for dry eye.

BACKGROUND: =Theoretically, autologous serum eye drops (AS) have a potential advantage over traditional therapies based on the assumption that ASserve not only as a lacrimal substitute to provide lubrication, but also contain other biochemical components mimicking natural tears more closely. The application of AS in dry eye treatment has gained popularity as a second-line therapy in the treatment of dry eye.Published studies on the subject indicate that autologous serum could be an effective treatment for dry eye. OBJECTIVES: To evaluate the efficacy and safety of AS compared to artificial tears for treating dry eye. SEARCH METHODS: We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2013, Issue 3),Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE,(January 1950 to April 2013), EMBASE (January 1980 to April 2013), Latin American and Caribbean Literature on Health Sciences(LILACS) (January 1982 to April 2013), themetaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov(www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We also searched the Science Citation Index Expanded database (September 2013) and reference lists of included studies. We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 15 April 2013. SELECTION CRITERIA: We included randomized controlled trials (RCTs) in which AS was compared to artificial tears in the treatment of dry eye in adults. DATA COLLECTION AND ANALYSIS: Two review authors independently screened all titles and abstracts and assessed full-text articles of potentially eligible trials. Two review authors extracted data and assessed the methodological quality and characteristics of the included trials.We contacted investigators for missing data. For both primary and secondary outcomes, we reported mean differences with corresponding 95% confidence intervals(CIs) for continuous outcomes. MAIN RESULTS: We identified four eligible RCTs in which AS was compared with artificial tear treatment or saline in individuals (n = 72 participants)with dry eye of various etiologies (Sjögren's syndrome-related dry eye, non-Sjögren's syndrome dry eye and postoperative dry eye induced by laser-assisted in situ keratomileusis (LASIK)). The quality of the evidence provided by these trials was variable. A majority of the risk of bias domains were judged to have an unclear risk of bias in two trials owing to insufficient reporting of trial characteristics.One trial was considered to have a low risk of bias for most domains while another was considered to have a high risk of bias for most domains. Incomplete outcome reporting and heterogeneity in the participant populations and follow-up periods prevented the inclusion of these trials in a summary meta-analysis. For the primary outcome, improvement in participant-reported symptoms at one month, one trial (12 participants) showed no difference in participant-reported symptoms between 20% AS and artificial tears. Based on the results of two trials in 32 participants, 20% AS may provide some improvement in participant-reported symptoms compared to traditional artificial tears after two weeks of treatment. One trial also showed positive results with a mean difference in tear breakup time (TBUT) of 2.00 seconds (95% CI 0.99 to 3.01 seconds) between 20% AS and artificial tears after two weeks, which were not similar to findings from the other trials. Based on all other objective clinical assessments included in this review, AS was not associated with improvements in aqueous tear production measured by Schirmer's test (two trials, 33 participants), ocular surface condition with fluorescein (four trials, 72 participants) or Rose Bengal staining (three trials, 60 participants), and epithelial metaplasia by impression cytology compared to artificial tears (one trial, 12 participants). Data on adverse effects were not reported by three of the included studies. In one study, there were no serious adverse events reported with the collection of and treatment with AS. AUTHORS' CONCLUSIONS: Overall there was inconsistency in the possible benefits of AS in improving participant-reported symptoms and TBUT and lack of effect based on other objective clinical measures. Well-planned, large, high-quality RCTs are warranted, in different severities of dry eye and using standardized questionnaires to measure participant-reported outcomes and objective clinical tests as well as objective biomarkers to assess the benefit of AS therapy for dry eye.

Hypopyon uveitis following LASIK in a patient with ulcerative colitis.

PURPOSE: To present a case of unilateral hypopyon uveitis that began 15 days after uneventful bilateral LASIK in a 24-year-old man with an undisclosed history of ulcerative colitis. METHODS: Case report. RESULTS: The hypopyon uveitis completely resolved after treatment with aggressive topical and oral steroid agents in combination with topical antibiotic coverage. CONCLUSIONS: Although rare, visually significant hypopyon uveitis may arise after LASIK in the setting of ulcerative colitis and positive human leukocyte antigen (HLA) B27. Early recognition and treatment can result in an excellent outcome. The exact relationship between hypopyon uveitis and LASIK is impossible to ascertain.

The intraoperative impression and postoperative outcomes of gamma-irradiated corneas in corneal and glaucoma patch surgery.

PURPOSE: To report the short-term outcome of gamma-irradiated sterile cornea in corneal and glaucoma patch graft surgeries when viable endothelium is not necessary. METHODS: Surgeons who have used the irradiated corneas were asked to rate their impression from 1 (fair) to 4 (very good). Specific intraoperative questions included availability, ease of use, clarity, thickness, tensile strength, and suturing. Postoperative outcomes included epithelialization, biological incorporation, and clarity of tissue, as well as any adverse outcomes. RESULTS: Irradiated sterile cornea has been used in more than 150 surgeries so far. The major uses for irradiated cornea were as glaucoma patch graft (65.3%), as corneal patch graft (14%), in anterior lamellar keratoplasty (10.7%), and in keratoprosthesis (10%). The mean score for packaging of tissue was 3.75 (SD, 0.45), ease of use 3.83 (SD, 0.39), clarity 3.62 (SD, 0.51), thickness 3.67 (SD, 0.49), tensile strength 3.64 (SD, 0.50), and suturing 3.62 (SD, 0.65). Postoperative outcomes were also favorable, including epithelialization (mean ± SD, 3.46 ± 0.69), biological incorporation (mean ± SD, 3.46 ± 0.69), and clarity (mean ± SD, 3.43 ± 0.85). There were 4 episodes of corneal melt (all occurred in patients with previous corneal melt). There were no reported cases of tissue rejection or infection. CONCLUSIONS: Gamma-irradiated sterile cornea is a promising new development that may help increase the supply of donor cornea tissue. It virtually eliminates the risk of infection while providing a long shelf life. It is particularly helpful in emergency situations or in remote areas. However, longer follow-up and a prospective study comparing the outcomes of the irradiated corneas with those of the optisol-stored corneas are needed.

Transforming growth factor-ß signaling pathway activation in Keratoconus.

PURPOSE: To assess the presence of transforming growth factor-ß (TGFß) pathway markers in the epithelium of keratoconus patient corneas. DESIGN: Retrospective, comparative case series of laboratory specimens. METHODS: Immunohistochemistry results for TGFß2, total TGFß, mothers against decacentaplegic homolog (Smad) 2, and phosphorylated Smad2 was performed on formalin-fixed, paraffin-embedded sections of keratoconus patient corneas and normal corneas from human autopsy eyes. Keratoconus patient corneas were divided in two groups, depending on their severity based on keratometer readings and pachymetry. Autopsy controls were age-matched with the keratoconus cases. Immunohistochemistry signal quantification was performed using automated software. Real-time reverse-transcriptase polymerase chain reaction was performed on total ribonucleic acid of epithelium of keratoconus patient corneas and autopsy control corneas. RESULTS: Immunohistochemistry quantification showed a significant increase in mean signal in the group of severe keratoconus cases compared with normal corneas for TGFß2 and phosphorylated Smad2 (P < .05). Immunohistochemistry analysis using antibodies against total TGFß and Smad2 did not show any significant increase in the keratoconus cases versus the autopsy controls. Reverse-transcriptase polymerase chain reaction exhibited elevated messenger ribonucleic acid levels of Smad2 and TGFß2 in severe keratoconus corneal epithelium. CONCLUSIONS: This work shows increased TGFß pathway markers in severe keratoconus cases and provides the rationale for investigating TGFß signaling further in the pathophysiology of keratoconus.

Descemet-stripping automated endothelial keratoplasty: a successful alternative to repeat penetrating keratoplasty.

BACKGROUND: Although Descemet-stripping automated endothelial keratoplasty has replaced penetrating keratoplasty for primary treatment of endothelial disorders, many patients have already undergone penetrating keratoplasty. It is unclear when repeat penetrating keratoplasty is necessary or when endothelial keratoplasty may restore clarity to a failed graft. DESIGN: Retrospective case series of patients undergoing Descemet-stripping automated endothelial keratoplasty after penetrating keratoplasty by three surgeons at an academic tertiary care centre. PARTICIPANTS: Eight patients with Descemet-stripping automated endothelial keratoplasty after penetrating keratoplasty from 2006 to 2009. METHODS: Microkeratome-prepared Descemet-stripping automated endothelial keratoplasty donor tissue was used. In seven cases, the penetrating keratoplasty bed was neither stripped nor scraped, and in one, scraping only was performed. MAIN OUTCOME MEASURES: Preoperative and 6-month postoperative best-corrected visual acuities in logMAR (logarithm of the minimum angle of resolution). RESULTS: The average pre-Descemet-stripping automated endothelial keratoplasty best-corrected visual acuity was 1.375, and the average best-corrected visual acuity 6months postoperatively was logMAR 1.0, a 2.5-fold improvement in the minimum angle of resolution (P=0.22). Seven of the eight patients showed an improvement in best-corrected visual acuity, and one patient had failure of Descemet-stripping automated endothelial keratoplasty and required penetrating keratoplasty. Five had a postoperative event: one had a gap that resolved spontaneously, three required rebubblings (injections of air only without otherwise repositioning the graft), and one experienced graft failure. CONCLUSIONS: Descemet-stripping automated endothelial keratoplasty can successfully rescue a prior penetrating keratoplasty, even with a fairly high detachment rate. Given these favourable visual outcomes, further study of this promising strategy is justified.

Aqueous penetration of moxifloxacin 0.5% ophthalmic solution and besifloxacin 0.6% ophthalmic suspension in cataract surgery patients.

PURPOSE: To determine the aqueous humor concentrations of moxifloxacin and besifloxacin after routine preoperative topical dosing in patients having cataract surgery. SETTING: Wilmer Eye Institute, Johns Hopkins University, Baltimore, Maryland, USA. METHODS: In this prospective randomized parallel double-masked clinical trial, 1 drop of commercially available moxifloxacin 0.5% ophthalmic solution or besifloxacin 0.6% ophthalmic suspension was administered every 10 minutes for a total of 4 doses beginning 1 hour before routine cataract surgery. Aqueous humor was sampled via the paracentesis, and antibiotic concentrations were determined using validated high-performance liquid chromatography procedures. RESULTS: The study enrolled 50 patients. The aqueous concentration of the antibiotic agent was detectable in all 23 moxifloxacin samples and in 10 (40%) of the 25 besifloxacin samples (P<.0001, Pearson chi-square test). The mean aqueous concentration in the moxifloxacin samples was 50-fold higher than in the besifloxacin samples (1.6108 microg/mL versus 0.0319 microg/mL) when all samples were included (P<.0001, Wilcoxon test), while the moxifloxacin concentration was 38-fold higher than the besifloxacin concentration (1.6108 microg/mL versus 0.0422 microg/mL) in the samples with detectable antibiotic agent (P<.0001). CONCLUSIONS: After topical preoperative administration, moxifloxacin 0.5% ophthalmic solution had a 38-fold to 50-fold higher concentration in the aqueous humor than besifloxacin 0.6% ophthalmic suspension. Besifloxacin was undetectable in more than half the aqueous humor samples.

Progression of age-related macular degeneration after cataract surgery.

OBJECTIVE: To document age-related macular degeneration (AMD) progression after cataract surgery. METHODS: Surgeons prospectively enrolled patients with nonneovascular AMD who were awaiting cataract surgery. Fluorescein angiography was performed preoperatively and at the postoperative week 1, month 3, and month 12 visits. Incidence of neovascular AMD development within 12 months after operation was the primary outcome measure. RESULTS: A total of 108 subjects were enrolled. Of 86 eyes with preoperatively photographically confirmed nonneovascular AMD, 71 had gradable images by month 12. Neovascular AMD was observed in 9 of 71 eyes (12.7%; 95% confidence interval, 6.0%-22.7%). The progression rate between week 1 and month 12 decreased to 3 of 65 eyes (4.6%; 95% confidence interval, 1.0%-12.9%) after excluding 5 neovascular events identified on the postoperative week 1 visit and 1 case with missing photographs at this visit. CONCLUSION: The low incidence rate of neovascular AMD development between 1 week and 1 year after cataract surgery did not support the hypothesis that cataract surgery increases the risk of AMD progression. Several eyes appeared to have disease progression on postsurgery week 1 fluorescein angiograms, suggesting that many cases of presumed progression to neovascular AMD following cataract surgery may have been present prior to cataract surgery, but not recognized owing to lens opacity.

Secondary angle closure caused by air migrating behind the pupil in descemet stripping endothelial keratoplasty.

PURPOSE: To report secondary angle closure caused by air migrating behind the pupil in the context of intraocular pressure (IOP) elevation in the early postoperative period after Descemet stripping endothelial keratoplasty (DSEK). METHODS: A retrospective case series was conducted on 100 consecutive DSEK cases from 90 patients undergoing DSEK because of corneal disease from Fuchs corneal dystrophy, pseudophakic bullous keratopathy, aphakic bullous keratopathy, and iridocorneal endothelial syndrome. Preoperative and postoperative slit-lamp examinations and IOP measurements were ascertained for all 100 eyes. Main outcome measures included preoperative and postoperative IOP. RESULTS: Thirteen of 100 eyes developed an IOP rise of greater than 30 mm Hg on the first postoperative day. Six of these 13 patients developed angle closure from air migrating posterior to the iris and causing iridocorneal adhesions. One of these 13 patients developed pupillary block from air anterior to iris. Six of 13 patients developed increased IOP without pupillary block or iridocorneal adhesions and had a history of preexisting primary or secondary glaucoma. CONCLUSIONS: A secondary angle closure associated with DSEK is reported with air migrating behind the iris, resulting in extensive iridocorneal adhesions. An acute increase in IOP after DSEK can also be induced by air anterior to the iris causing pupillary block. IOP spikes are much more common in the first few postoperative days after DSEK. Medical treatment can occasionally resolve air posterior to the iris, but if iridocorneal adhesions are extensive and persistent, air removal and angle reformation may be necessary.