The outcomes of corneal sight rehabilitating surgery in Stevens-Johnson syndrome: case series.

PURPOSE: To summarize the outcomes of corneal sight rehabilitating surgery in Stevens-Johnson syndrome (SJS). METHODS: This is a retrospective analysis of a consecutive case series. Twenty-four eyes of 18 SJS patients were included in this study. The ocular parameters, surgical procedures, postoperative complications, and additional treatments of the cases were reviewed. RESULTS: A total of 29 corneal sight rehabilitating surgeries, which consists of 9 keratoplasties, 8 Keratolimbal allograft (KLAL) and 12 combined surgeries (keratoplasty and KLAL simultaneously) were performed on the 24 eyes. All patients were treated with glucocorticoid eyedrops and tacrolimus eyedrops for anti-rejection treatment without combining systemic immunosuppression, except two patients who were prescribed prednisone tablets for the management of systemic conditions. The mean follow-up period was 50.6 ± 28.1 months. The optimal visual acuity (VA) (0.74 ± 0.60 logarithm of the minimum angle of resolution [logMAR]) and endpoint VA (1.06 ± 0.82 logMAR) were both significantly better than the preoperative VA (1.96 ± 0.43 logMAR) (95% CI, p = 0.000). 57.1% patients (8/14) were no longer in the low vision spectrum, and 88.9% patients (8/9) were no longer blind. The mean epithelialization time was 7.1 ± 7.6 weeks. The success rate was 86.7%. Additional treatments for improving epithelialization included administration of serum eyedrops (n = 10), contact lens (n = 15), amniotic membrane transplantation (n = 6), and tarsorrhaphy (n = 8). Complications included delayed epithelialization (n = 4, over 12 weeks), glaucoma (n = 11), and severe allograft opacity (n = 4). Only one graft rejection was observed. CONCLUSIONS: Keratoplasty and KLAL can remarkably enhance VA and improve low vision or even eliminate blindness for ocular complications of SJS. The outcome of the surgeries was correlated with the preoperative ocular situation and choice of operative methods.

Glaucoma drainage device implantation and cyclophotocoagulation in the management of refractory glaucoma after Descemet-stripping automated endothelial keratoplasty.

AIM: To compare the surgical outcomes of glaucoma drainage device implantation (GDI) and trans-scleral neodymium:YAG cyclophotocoagulation (CPC) in the management of refractory glaucoma after Descemet-stripping automated endothelial keratoplasty (DSAEK). METHODS: This retrospective study on observational case series enrolled 29 patients who underwent DSAEK and posterior anti-glaucoma surgery (15 with GDI and 14 with CPC). The main outcome measures were intraocular pressure (IOP), glaucoma surgery success rate (defined as IOP of 6-21 mm Hg without additional anti-glaucoma operation), number of glaucoma medications, endothelial graft status, and best-corrected visual acuity (BCVA). RESULTS: The mean follow-up time was 34.1 and 21.0mo for DSAEK or glaucoma surgeries, both for the GDI and CPC groups. Both groups showed significant IOP reduction after glaucoma surgery. The GDI group presented a significantly higher success rate in IOP control than the CPC group (60% vs 21.4%, P=0.03). Both procedures significantly decreased the number of glaucoma medications (P=0.03). Forty percent and 57% of cases in the GDI and the CPC group, respectively, experienced endothelial graft failure during follow-up (P=0.36). Significantly worse BCVA after surgery was observed in the CPC group but not in the GDI group. CONCLUSION: Both GDI and CPC significantly decrease IOP in eyes with glaucoma after DSAEK. GDI is preferable to CPC in refractory glaucoma cases after DSAEK, as it manifests a significantly higher success rate for IOP control, similar endothelial graft failure rate, and relatively preserves BCVA than CPC.

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.

Axenfeld-Rieger syndrome: a novel histopathologic finding associated with corneal abnormalities.

BACKGROUND: Axenfeld-Rieger syndrome (ARS) is a rare kind of anterior segment dysgenesis (ASD). The most common ocular features of ARS are posterior embryotoxon and iris hypoplasia, while some patients may manifest as corneal opacity and edema. However, the current understanding of how ARS affects the cornea is still incomplete. This study reports a novel histopathological finding of ARS, complicating corneal abnormalities, including congenital corneal opacity and irreversible endothelial decompensation. METHODS: This retrospective study included 6 eyes of 3 ARS patients, 5 of which underwent keratoplasty for irreversible endothelial decompensation from May 2016 to January 2019. No eye had a history of surgery. We reviewed the data of epidemiology, clinical manifestations and histopathologic examinations. RESULTS: Five eyes developed irreversible endothelial decompensation, among which 4 were born with corneal opacity. One eye exhibited transparent cornea but showed a continuous loss of endothelial cells in the absence of surgery and elevated intraocular pressure thereafter. Anterior segment optical coherence tomography photographs showed that anterior synechia existed in the area with corneal opacities, where we found the interlayer splitting of the Descemet membrane inserted by hypoplastic iris and a basement membrane-like structure under a light microscope. CONCLUSION: Anterior synechia might be associated with corneal abnormalities in ARS patients. The novel histopathologic finding revealed the internal relation between anterior segment dysgenesis and would help explore the inner mechanism of corneal abnormalities in ARS.

Descemet Stripping Automated Endothelial Keratoplasty in Thick Corneas.

Purpose: To evaluate the outcomes of Descemet's Stripping Automated Endothelial Keratoplasty (DSAEK) in corneas > 820 microns in thickness. Methods: This retrospective study included 30 eyes of 30 patients who underwent DSAEK. Endothelial cell destiny (ECD) and corneal thickness were recorded before surgery and at 1 and 12 months postoperatively. Patients were divided into two groups (≤ 820 microns and > 820 microns) based on median preoperative corneal thickness. Linear regression analyses were used to investigate the correlations between ECD and preoperative corneal thickness. Results: Recipient corneal thickness (RCT) and postoperative central cornea thickness had a statistically significant difference 1 month after surgery (p = 0.03, p = 0.08, respectively). BCVA and ECD did not have a statistical difference in the two groups at 1 month and 12 months after DSAEK. Conclusions: BCVA, ECD and corneal thickness were similar at 12 months after DSAEK in thick corneas. DSAEK is a viable surgical option in thick corneas.

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.

Severe Corneal Edema Increases ECL From Grafts After DSAEK-Corneal Edema and ECL After DSAEK.

OBJECTIVES: To determine the relationship between the preoperative degree of corneal edema in the recipient and the endothelial cell density in grafts after Descemet stripping automated endothelial keratoplasty (DSAEK). METHODS: This retrospective case series enrolled 111 eyes of 107 patients who underwent DSAEK. The preoperative and postoperative central corneal thickness (CCT) was measured by anterior-segment optical coherence tomography. Eyes were divided into three groups according to the preoperative recipient CCT: group A (mild edema): 550 µm

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.

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.

Keratometric measurements and IOL calculations in pseudophakic post-DSAEK patients.

BACKGROUND: To compare different K readings in pseudophakic patients post-Descemet's stripping automated endothelial keratoplasty (DSAEK) and evaluate corresponding prediction errors in intraocular lens (IOL) power calculations. METHODS: Subjects that underwent cataract surgery and DSAEK surgery at least 3 and 6 months prior, respectively, and IOL implantation in the capsular bag were included in this study. Manifest refraction and IOL information were recorded. A Scheimpflug keratometer (Pentacam) was used for corneal measurements, including the mean anterior and posterior radii of curvature, simulated keratometer (SimK), true net power (TNP), and equivalent K reading (EKR) at the 4.0-mm zone. Conventional keratometry was acquired using the IOLMaster (KMaster). The four K measurements were evaluated for calculating the predicted refraction. RESULTS: The study included 20 eyes from 19 subjects. The ratio of the posterior to the anterior corneal radius was 74.1 ± 3.24%. Comparison of the four keratometric methods (KMaster, SimK, EKR, and TNP) revealed statistically significant differences among all the methods besides KMaster and SimK. Of the four IOL calculation methods(KMaster, SimK, EKR and TNP method),the arithmetic prediction error of the KMaster, SimK, and EKR methods featured nonsignificant differences from zero(p = 0.07, 0.19 and 0.84 respectively); the EKR method calculated the highest percentage of eyes with IOLs within the prediction error. CONCLUSIONS: IOL calculations in post-DSAEK eyes using KMaster, SimK, and EKR can yield small refractive errors after surgery. The EKR (4.0-mm diameter) method was found to be the most accurate.

Appositional angle closure in Chinese with primary angle closure and primary angle closure glaucoma after laser peripheral iridotomy.

PURPOSE: To determine the prevalence of appositional angle closure (AAC) after laser peripheral iridotomy (LPI) in the eyes of Chinese patients with primary angle closure (PAC) and primary angle closure glaucoma (PACG) and to evaluate its pathogenesis by investigating anatomic characteristics. METHODS: This was a cross-sectional observational study. PAC and PACG subjects were consecutively enrolled after LPI. Ultrasound biomicroscopy (UBM) images, obtained in darkness, of each quadrant without peripheral anterior synechia (PAS) under gonioscopy were qualitatively assessed. Darkroom provocative test (DRPT) was also performed. RESULTS: A total of 134 eyes of 134 patients were enrolled. AAC was observed in ≥ 1 quadrant of UBM image in 85 subjects (63.4%). There were 116 randomly selected quadrants without PAS for 134 patients (86.6%). AAC existed in 38 quadrants (32.8%). Among these, plateau iris accounted for 44.7%, anteriorly inserted iris for 13.2%, thick iris for 13.2%, and anteriorly inserted iris combined with thick iris for 18.4% of the total. One hundred fifteen patients underwent DRPT and its positive rate of eyes with AAC ≥ 2 quadrants (37.5% [12 of 32 patients]) was significantly higher than those ≤ 1 quadrant (16.9% [14 of 83 patients]; P = 0.018). However, no significant differences were found between eyes with nonsynechia plateau iris ≥ 2 quadrants (36.4% [4 of 11 patients]) and those ≤ 1 quadrant (21.2% [22 of 104 patients]; P = 0.266). CONCLUSIONS: Approximately two-thirds of PAC and PACG eyes of Chinese patients after LPI had AAC. Plateau iris accounted for less than 50% of AAC. Other factors such as a thick peripheral iris and an anteriorly inserted iris also contributed to AAC. DRPT results suggested AAC might have more functional meaning than plateau iris.

Pathological characteristics of the different stages of Acanthamoeba keratitis.

AIMS: To classify the clinical stages of Acanthamoeba keratitis (AK), and clarify the relationship between pathological changes and clinical features. METHODS AND RESULTS: Between January 2007 and May 2012, AK was diagnosed in 11 eyes by pathological examination and confocal laser scanning microscopy. Pathological investigation of all cornea samples from keratoplasty was done with periodic acid-Schiff and haematoxylin and eosin stains. AK clinical stage, pathological features and postoperative treatment were studied retrospectively. The 11 cases were classified into development stage, convalescence stage, or cicatricial stage. In the development stage, marked conjunctival hyperaemia, a corneal epithelial defect, obvious corneal infiltration and progressive inflammation were seen; pathological changes comprised abundant inflammatory cells and a rounded cyst in the oedematous stroma, as well as a very small amount of neovascularization. In the convalescence cases, moderate conjunctival hyperaemia, corneal disciform structures, repair of the corneal epithelial defect and abundant neovascularization were seen; pathological changes included significant tissue necrosis and a small, shrunken cyst in the stroma, as well as significant neovascularization. In the cicatricial stage, keratoleukoma was seen; pathological changes comprised a few inflammatory cells and shrunken cysts scattered in the stroma. There were no cases of recurrence. CONCLUSIONS: The pathological features of different clinical stages confirmed the new clinical classification of AK.