Corneal Perforation as a Rare and Late Manifestation of Choroidal Melanoma.

PURPOSE: To report a case of corneal perforation as a rare and late manifestation of choroidal melanoma and to highlight the major histopathological findings of this unusual combined clinical presentation. METHODS: A 74-year-old male patient presented to our department due to corneal perforation of the right eye with the absence of light perception for 6 months. The intraocular pressure was hard on palpation. Because of the protracted finding and reduced visual prognosis, primary enucleation was performed. RESULTS: The histopathological examination revealed choroidal melanoma with epithelioid and spindle cell components at the posterior pole, which was positive for Melan-A, Human Melanoma Black 45 (HMB45), BAP1, and SOX10. The anterior segment showed complete anterior chamber hemorrhage and blood remnants in the trabecular meshwork. The cornea displayed diffuse blood staining with hemosiderin and hemosiderin-loaded macrophages and keratocytes. No inflammatory cells were present near the corneal perforation, which had a width of 3 mm. Intraocular heterotopic ossification was indicative of a long-standing condition. Postoperative cancer staging was normal. CONCLUSION: Corneal perforation should be considered as a very rare and late manifestation of advanced choroidal melanoma and may result from interaction between intraocular hemorrhage, elevated IOP, and its secondary signs such as corneal blood staining.

Simultaneous Bilateral Primary Occlusion of the Ophthalmic Artery due to Florid Giant Cell Arteritis.

PURPOSE: To report a case of simultaneous bilateral ophthalmic artery occlusion in diagnosed giant cell arteritis (GCA). OBSERVATIONS: A 77-year-old male patient presented to the emergency department with simultaneous vision loss in both eyes for 3 hours. Headache at both temples and jaw claudication had been present for 3 weeks. Laboratory values demonstrated an initially increased C-reactive protein (CRP) of 202.0 mg/L and an erythrocyte sedimentation rate (ESR) of 100 mm within the first 20 minutes. Duplex sonography of the right and left temporal arteries revealed a "halo sign." A case of GCA was suspected, and intravenous high-dose methylprednisolone therapy was immediately administered. The clinical examination revealed a bilateral central retinal artery occlusion and fluorescein angiography showed a hot optic disc in the right eye and patchy choroidal hypoperfusion in both eyes. Biopsy of the left temporal artery was performed, which confirmed a florid temporal arteritis with complete thrombotic occlusion of the vascular lumen. Despite a good response to the administered therapy (CRP 17.0 mg/L 1 week after initiation), the visual prognosis was significantly limited through retinal and optic nerve involvement. By the follow-up examination 8 weeks later, the near visual acuity was 20/400 in the right and left eye at a distance of 16 inches. CONCLUSION AND IMPORTANCE: We hereby present a simultaneous bilateral ophthalmic artery occlusion as a rare complication of GCA. The combination of central retinal artery occlusion, arteritic anterior ischemic optic neuropathy, and choroidal hypoperfusion suggests an acute inflammatory involvement of the ophthalmic artery. In cases of the slightest suspicion of giant cell arteritis, an immediate high-dose steroid therapy initiation is of utmost importance.

Descemet Membrane Endothelial Keratoplasty (DMEK) in Previously Vitrectomized Eyes: Complications and Clinical Outcomes.

PURPOSE: To evaluate the results and complications of Descemet membrane endothelial keratoplasty (DMEK) in previously vitrectomized eyes. DESIGN: Retrospective study of 35 eyes that had undergone DMEK, due to Fuchs endothelial corneal dystrophy (FECD), at our department with a follow-up after 6 months postoperatively. We compared the intraoperative procedure, complications, and results of DMEK between 14 previously vitrectomized pseudophakic eyes (group 1) and a control group of 21 pseudophakic non-vitrectomized eyes (group 2). RESULTS: The unfolding time (in minutes) was significantly longer in group 1 than in group 2 (10.5 ± 6.4 vs. 3.2 ± 1.5, p < 0.01). A single re-bubbling was needed in 8 patients in group 1 (57.1%) and in 3 patients in group 2 (14.2%) (p < 0.01). Repeated re-bubbling (≥ 1 time) was performed in only 5 patients of group 1 (35.7%). There was significant postoperative improvement in best-corrected visual acuity (BCVA, in LogMAR) in both groups (p = 0.04 in group 1 and p < 0.01 in group 2). The central corneal thickness (CCT, in µm) did not differ significantly between the two groups preoperatively (p = 0.4) or postoperatively (p = 0.1). However, the CCT decreased significantly postoperatively in both groups (p < 0.01 in both groups). The postoperative endothelial cell density (ECD in cell/mm²) was significantly lower in group 1 than in group 2 (p = 0.03). CONCLUSION: DMEK in previously vitrectomized eyes presents a surgical challenge, which requires special, and sometimes unpredictable, intraoperative maneuvers, but good functional and morphological results can be achieved. The use of the endothelial Descemet membrane lamellae (EDML) of older donors might be recommended to facilitate the intraoperative unfolding process.

Negative impact of dextran in organ culture media for pre-stripped tissue preservation on DMEK (Descemet membrane endothelial keratoplasty) outcome.

PURPOSE: To assess the morphological and functional outcomes of Descemet membrane endothelial keratoplasty (DMEK) performed with pre-stripped tissue preserved in organ culture medium containing dextran compared to tissue preserved in dextran-free medium. METHODS: In this retrospective study, we reviewed the clinical records of 103 patients who underwent DMEK surgery with pre-stripped tissue in our department between June 2015 and September 2016. The endothelium-Descemet membrane layer was preserved in organ culture medium for a maximum of 48 h for all patients. For group 1, 49 endothelium-Descemet membrane (EDM) were stripped and preserved in medium 1 (dextran-free organ culture medium), while 54 EDM were stripped and preserved in medium 2 (organ culture medium supplemented with 6% dextran T-500) for group 2. Outcome measures included best-corrected visual acuity (BCVA), central corneal thickness (CCT), and endothelial cell density (ECD) of all eyes in both groups at three consecutive postoperative time points: 2 weeks, 6 weeks, and 6 months postoperatively. We also compared the repeat keratoplasty rates between the groups. RESULTS: Group 1 showed a statistically significant better BCVA compared to group 2 at each time point (p < 0.05). The percentage of grafts achieving 0.5 or better after 6 months in group 1 was 96% and in group 2, it was 66% (P < 0.001). CCT was significantly lower in group 1 compared to group 2 at 2 weeks and 6 months after surgery (p < 0.05). ECD was comparable between donor grafts before surgery but was significantly greater in groups 1 after 2 and 6 weeks (p < 0.05), but not after 6 months. Necessity for repeat keratoplasty (repeat DMEK, subsequent penetrating keratoplasty (PKP)) was significantly lower in group 1 (p < 0.05). CONCLUSIONS: Pre-stripped tissue for DMEK preserved in dextran-free medium led to better visual recovery, thinner postoperative corneas, a higher endothelial cell density, and a lower rate of repeat keratoplasty, indicating that dextran has an unfavorable impact on the preservation of pre-stripped DMEK tissue.