Randomized Trial Comparing Amniotic Membrane Transplantation with Lamellar Corneal Graft for the Treatment of Corneal Thinning.

PURPOSE: There are few studies comparing different surgical procedures for the treatment of corneal thinning. Lamellar corneal transplantation (LCT) has been reported to be efficient, but its results can be jeopardized by allograft rejection, opacification, or high astigmatism. Amniotic membrane transplantation (AMT) has been considered a good alternative, but it is not as resistant as LCT and the tissue can be reabsorbed after surgery. METHODS: A prospective, randomized, interventional, and comparative study of consecutive patients with corneal thinning over 6 months was performed. Ophthalmological examination was performed before transplant surgery and then repeated 1, 7, 15, 30, 90, and 180 days after surgery and ultrasound biomicroscopy was performed before and then 30, 90, and 180 days after surgery to assess corneal thinning. RESULTS: Herpes simplex infection was the main cause of corneal thinning (9 eyes), followed by surgery (cataract, glaucoma, 5 cases), rheumatoid arthritis (1), chemical burn (1), perforating trauma (1), previous band keratopathy treatment (1), and Stevens-Johnson syndrome (1). Although all patients showed significant increase in final thickness in the area of thinning, it was higher in those submitted to LCT at 180 days postoperatively. Regardless of the surgical technique, all patients showed epithelialization. Patients undergoing AMT showed an 89% decrease in neovascularization. Final corrected distance visual acuity was better in patients submitted to AMT. CONCLUSIONS: LCT proved to be the best option for treating corneal thinning. AMT represents an alternative that allows good visual recovery but does not restore corneal thickness as efficiently as LCT.

Management of patients with confirmed and presumed mucous membrane pemphigoid undergoing entropion repair.

PURPOSE: To describe the outcomes and medical management necessary to achieve successful lid surgery in patients with biopsy-confirmed and presumed mucous membrane pemphigoid. DESIGN: Retrospective, interventional case series. METHODS: We included patients with positive biopsy results and cases with a typical clinical active bilateral presentation with negative biopsy results but classic features. We identified 11 operated eyes of 7 patients with lid malposition resulting from mucous membrane pemphigoid, particularly cicatricial entropion, that required surgical correction. Complete ophthalmologic history and examination were performed. The main outcome measures were control of ocular inflammation, progression of disease, and surgical success. RESULTS: A bandage lens was used in 8 (72.7%) eyes to protect the cornea while immunosuppression and control of disease activity were achieved. Control of ocular inflammation before lid surgery was achieved in all cases. Immunosuppressive treatment before lid surgery was used in all cases for a mean of 15.1 months (range, 8.2 to 33.1 months) and after surgery for a mean of 6.6 months (range, 3.0 to 11.2 months). The oral immunosuppressive drugs used were mycophenolate and cyclophosphamide. Prednisone was used concomitantly in 4 (57%) patients. Full surgical success was achieved in all patients, with 1 patient requiring a second intervention because of residual disease. The mean postoperative follow-up period was 20.8 months (range, 6.0 to 30.5 months). CONCLUSIONS: Successful entropion repair in patients with mucous membrane pemphigoid can be achieved if control of inflammation is attained before the procedure. Ocular surface protection while achieving disease control is essential in the management of these patients.

Randomized trial comparing multilayer amniotic membrane transplantation with scleral and corneal grafts for the treatment of scleral thinning after pterygium surgery associated with beta therapy.

PURPOSE: The aim of this study was to compare the use of multilayer amniotic membrane transplantation (AMT) with lamellar corneal transplantation (LCT) and lamellar scleral transplantation (LST) for the treatment of scleral thinning after pterygium surgery associated with beta therapy. METHODS: Twenty-six eyes from 26 different patients with scleral thinning as a consequence of beta therapy after pterygium surgery were evaluated at the Federal University of São Paulo, Brazil. Ophthalmologic examination and ultrasound biomicroscopy were performed to assess scleral thinning before the transplant surgery and then repeated at 30, 90, and 180 days after surgery. An increase in scleral thickness, epithelialization of the ocular surface, and preservation of the ocular globe were the main outcome measures. RESULTS: Irrespective of the surgical technique used (AMT, LCT, or LST), no clinical or statistical changes in corrected distance visual acuity were found in any of the patients during this study. The median preoperative scleral thickness was similar in all 3 groups: AMT = 0.45 mm, LST = 0.48 mm, and LCT = 0.52 mm (P = 0.257); however, 6 months after surgery, the median thickness in the AMT group (0.19) was significantly less than that of the LCT group (0.57) (P = 0.27) or the LST group (0.76) (P = 0.19). Epithelialization occurred in all the patients. CONCLUSIONS: LCT was the best option for the structural treatment of scleral thinning, followed by LST with a conjunctival flap. A high rate of reabsorption was found with AMT, which was the least effective of the 3 therapeutic options and should not be used for this condition.

Use of intraocular video endoscopic examination in the preoperative evaluation of keratoprosthesis surgery to assess visual potential.

PURPOSE: To determine the clinical utility of intraocular videoendoscopy examination for the evaluation of the retina and optic nerve in patients being considered for a Boston type I keratoprosthesis (KPro). DESIGN: Interventional case series study. METHODS: Ten patients with a history of corneal blindness caused by failed penetrating keratoplasty (PK) and inability to accurately assess visual potential were included in this study. Ophthalmologic examination, B-scan ultrasonography, and pars plana videoendoscopy were carried out to assess the retina and optic nerve before KPro. RESULTS: Posterior segment examination was successfully used to evaluate the retina and optic nerve of all patients with opaque corneas. Out of 10 patients that underwent endoscopic examination, 3 (30%) were considered to be adequate candidates for KPro surgery and 7 (70%) were not. This was based on visualized retinal disease and/or optic nerve pathology. Of the 3 patients that underwent KPro surgery, all of them had a significant improvement of vision, including counting fingers to 20/100, hand motion to 20/5, and light perception to 20/80, as suggested by the endoscopy preoperative examination. No complications of the endoscopy procedure were observed. CONCLUSIONS: This report demonstrates the successful use of intraocular videoendoscopy to rule out threats to a good visual outcome for patients being considered as candidates for KPro. Direct visualization of the posterior segment can be part of the preoperative algorithm in the decision process of performing a KPro surgery in patients when visual potential is questionable.

Transplantation of conjunctival epithelial cells cultivated ex vivo in patients with total limbal stem cell deficiency.

PURPOSE: To report the outcomes of transplantation of autologous conjunctival epithelial cells cultivated ex vivo (EVCAU) in patients with total limbal stem cell deficiency (LSCD). METHODS: EVCAU were cultivated on denuded human amniotic membrane and transplanted in 12 eyes of 10 patients with total LSCD. We evaluated the improvement in the defined clinical parameters of LSCD (loss of corneal epithelial transparency, superficial corneal neovascularization and epithelial irregularity/recurrent epithelial breakdown), vision acuity, impression cytology, immunocytochemical analysis (CK3/CK19), and the appearance of a regular hexagonal basal layer of cells on corneal confocal microscopy. Histologic and immunohistochemical features were studied in 3 corneal buttons of patients submitted to penetrating keratoplasty after EVCAU. RESULTS: Cultivated conjunctival epithelium formed 4 to 5 layers with the formation of basement membrane-like structures. Immunocytochemical analysis showed positivity for CK3, CK19, MUC5AC, Ki-67, P63, and ABCG2. The improvement of the clinical parameters for this treatment in our cohort was 10 of 12 (83.3%) in a mean follow-up time of 18.5 months (range, 15-26 months), and these eyes showed an improvement in impression cytology, immunocytochemistry, and in vivo confocal analysis. Corneal buttons showed a well-formed epithelium with 5 to 6 layers, with rare cells periodic acid-Schiff+, and positivity for CK3, CK19, P63, connexin 43, and MUC5AC. CONCLUSION: We demonstrated the preliminary results of transplantation of EVCAU for corneal surface reconstruction in cases with total LSCD. Future studies are needed to further assess the long-term efficacy of this procedure.