[Current possibilities for the diagnosis and treatment of pterygium]. / Sovremennye vozmozhnosti diagnostiki i lecheniya pterigiuma.

Pterygium is a common inflammatory-proliferative disease characterized by the invasion of degeneratively altered fibrovascular tissue into the cornea. This literature review analyzes the etiological factors and pathogenetic concepts of its development, describes modern methods of diagnostics and surgical treatment of pterygium, and pays particular attention to the assessment of structural and functional changes in the cornea occurring during the growth of pterygium and after its excision.

[Epithelial ingrowth after anterior lamellar keratoplasty (clinical observation)]. / Vrastanie epiteliya posle perednei posloinoi keratoplastiki (klinicheskoe nablyudenie).

Epithelial ingrowth (EI) is a rarely occurring complication of surgeries on the anterior eye segment characterized by migration and proliferation of epithelial cells along the wound tract or into the anterior chamber. Several decades ago, EI often led to severe complications, including enucleation. Modern treatment methods allow not only removing the pathological focus of EI, but also minimizing the risk of its reoccurrence. This article presents a clinical case of EI after anterior lamellar keratoplasty involving formation of implant bed under the pathological focus without cutting open the interface zone. The technique helps minimize dissemination of epithelial cells in the area of the lesion. To prevent growth reoccurrence, the method was supplemented with application of a cytostatic agent. The treatment resulted in stable remission throughout the follow-up period (26 months).

[Salzmann nodular degeneration: pathogenesis, clinical characteristics and treatment]. / Uzelkovaya degeneratsiya Zal'tsmana: osobennosti patogeneza, klinicheskoi kartiny i lecheniya.

Salzmann nodular degeneration (SND) is a rare non-inflammatory disease observed primarily in middle-aged women. The disease generally occurs in patients with chronic inflammation of the anterior ocular surface. Its etiopathogenesis remains poorly investigated. This literature review describes clinical manifestations, risk factors and diagnostic methods, evaluates the effectiveness of different therapeutic and surgical treatment methods. Understanding of the pathogenetic mechanisms, precise diagnosis and identification of the risk factors can help clinical physicians make the optimal choice of treatment strategy and achieve the best clinical outcomes.

[Antiangiogenic therapy in the surgical treatment of pterygium]. / Antiangiogennaya terapiya v khirurgicheskom lechenii pterigiuma.

PURPOSE: To evaluate the effectiveness and safety of adjuvant anti-VEGF therapy in the surgical treatment of pterygium, and to determine the indications for its use. MATERIAL AND METHODS: The study included 67 patients (69 eyes) with grade II-IV pterygium. Patients age was 58.8±12.6 years on average. Best corrected visual acuity (BCVA) varied between 0.01 and 1.0 (0.77±0.24). The patients were divided into 3 groups. The first group included 19 patients (19 eyes) with grade II-III pterygium who underwent «bare sclera¼ surgery and used aflibercept as adjuvant therapy. The second group included 21 patients (21 eyes) with grade II-IV pterygium who underwent auto conjunctival grafting surgery with no adjuvant therapy. The third group included 27 patients (29 eyes) with grade II-IV pterygium who had it removed in combination with single-time peripheral lamellar keratoplasty (PLK) and underwent adjuvant aflibercept therapy. RESULTS: Among patients who underwent pterygium excision with adjuvant antiangiogenic therapy there were 5 cases (26%) of relapse during the observation period (23.38±8.96 months), among patients after pterygium excision with auto conjunctival plastic surgery - also 5 cases (24%) of relapse, and among patients who underwent LKP combined with anti-VEGF therapy there was only 1 case (3%) of relapse. Astigmatism has decreased by 0.24±0.5 (p=0.052) in the first group, by 1.21±1.0 (p<0.05) in the second group, and by 1.64±1.54 (p<0.05) in the third group compared with pre-surgical values, thus increasing average BCVA in all 3 patient groups by 0.1±0.13, 0.07±0.11 and 0.15±0.15, respectively. CONCLUSION: The use of anti-VEGF agents as adjuvant therapy in the surgical treatment of pterygium is a safe method of reducing postoperative inflammation, fibrovascular proliferation and, subsequently, the amount of relapses.

[Antiangiogenic therapy in high-risk keratoplasty]. / Antiangiogennaya terapiya pri keratoplastike vysokogo riska.

PURPOSE: To analyze the effectiveness and safety of VEGF inhibitor used to improve keratoconus transplant survival in patients with corneal neovascularization as stand-alone and in combination with laser coagulation of ingrowing vessels before keratoplasty. MATERIAL AND METHODS: The study included 56 patients (56 eyes) with corneal opacifications of various etiology complicated by corneal neovascularization (CNV). The patients were divided into three groups. The 1st group included 27 patients with diffuse CNV who were undergoing an antiangiogenic therapy using anti-VEGF drug, the 2nd group - 14 patients with stem cell CNV who underwent laser coagulation of major corneal vessels combined with subconjunctival administration of drug before keratoplasty; the control group consisted of 15 patients with mixed type CNV who were undergoing conventional treatment without antiangiogenic therapy. RESULTS: During the follow-up (24.5±4.84 months, 4 to 25 months), transplant rejection reaction was recorded in 7 (23%) patients of the 1st group, 5 (35%) patients of the 2nd group and 9 (60%) patients of the control group. CONCLUSION: Subconjunctival administration of Aflibercept as a stand-alone measure and in combination with laser coagulation of ingrowing vessels may increase the chances of transparent transplant acceptance in high-risk keratoplasty.

[Mushroom keratoplasty in rosacea keratitis complicated by corneal perforation (a clinical case)]. / Gribovidnaia keratoplastika pri rozatsea-keratite, oslozhnennom perforatsiei rogovitsy (klinicheskii sluchai).

Rosacea is a polyethiologic chronic inflammatory disease with varying clinical manifestations. It is primarily a dermatologic disease, which often manifests in the eyes affecting eyelids, cornea and conjunctiva. The leading role in the pathological process belongs to disruption of regulatory mechanisms in the vascular, immune and nervous systems. It is accompanied by increased levels of metalloproteinases and vascular endothelial growth factor (VEGF). Treatment depends on the severity of the disease and may vary from hygiene of the eyelid margins and use of artificial tears for dry eye disease management, to antibiotics and anti-inflammatory agents in moderate cases, and surgical treatment in severe or neglected state. A clinical case of severe rosacea shows that keratoplasty with mushroom-shaped profile of the surgical incision helps achieve good functional results and reduce the post-operative rehabilitation time, while significantly reducing the risk of postsurgical complications. Anti-VEGF therapy significantly reduces the risk of histoincompatibility reaction typical for rosacea keratitis.

[Peripheral lamellar keratoplasty in treatment of relapsing pterygium]. / Perifericheskaia posloinaia keratoplastika v lechenii retsidiviruiushchego pterigiuma.

PURPOSE: To evaluate the effectiveness and safety of peripheral lamellar keratoplasty (LKP) for treating relapsing pterygium. MATERIAL AND METHODS: The study was conducted in the period of 2007-2017 and included 84 patients (91 eyes) with stage II-IV relapsing pterygium. Best corrected visual acuity (BCVA) before the surgery was in average 0.65±0.28 (0.01 to 1.0). Astigmatism varied from 0.5 to 6.5 D (mean 3.41±2.06). All patients underwent pterygium removal surgery followed by LKP. The analyzed parameters included visual acuity, refraction error before and after the surgery, frequency of relapses and post-operative complications. RESULTS: The follow-up period was 4 months to 10 years (mean 30.9±25.4 months). BCVA after the surgery was 0.1-1.2 (mean 0.83±0.24), post-operative astigmatism - 0 to 3.5 D (1.08±0.62). BCVA has improved and remained stable in 86 (94.5%) out of 91 eyes, decrease of visual acuity was observed in 5 cases (5.5%). Frequent relapse of pterygium happened in 5 cases (5.5%), was non-progressing and required no surgical treatment. CONCLUSION: LKP is an effective and safe method of surgical treatment of relapsing pterygium that provides good optical, tectonic and anti-relapsing results thanks to barrier properties of the layered transplant.

[Pterygium: etiology, pathogenesis, treatment]. / Pterigium: étiologiia, patogenez, lechenie.

Pterygium is a degenerative condition characterized by fibrovascular outgrowth of conjunctiva over the cornea. Many theories exist that try to explain its pathogenesis. The current belief is that this disease is multifactorial with ultraviolet radiation being the most important trigger. Attention is also paid to such factors as tear film changes, cytokines and growth factors disbalance, immunologic disturbances, genetic mutations, and viral infections. Modern classifications consider the rate of fibrovascular growth, its progressive potential, and histological features. In the beginning pterygium is usually asymptomatic, however, dry eye manifestations may be present, such as burning, itching, and/or tearing. As the lesion grows toward the optical zone, visual acuity gets compromised, and thus, surgical treatment is required. Because of recurrences and repeated surgeries, the growth of the lesion may become more aggressive and cause irregular astigmatism. Comprehensive surgery of pterygium is aimed at not only removing the lesion, but also preventing recurrences. Advisable are modified bare sclera techniques with subsequent transposition of the conjunctival flap, conjunctival autotransplantation, amniotic membrane transplantation, and peripheral lamellar keratoplasty (in cases of significant ingrowth). In some cases, antirecurrent adjuvant therapy may be considered that involves the use of mitomycin C, 5-fluoruracil, and VEGF inhibitors. However, the search for the best treatment for pterygium, i.e. an easy to perform, cosmetically-friendly method associated with minimal risk of recurrences and/or complications, remains an interest of modern ophthalmology.

[Mechanisms of corneal neovascularization and modern options for its suppression]. / Mekhanizmy rogovichnoi neovaskuliarizatsii i sovremennye vozmozhnosti ee podavleniia.

Quite a number of pathological factors exist that can disturb the balance between anti-angiogenic and proangiogenic mechanisms, thus causing vascularization of the cornea. The neovessels are immature, ill-formed, and show increased permeability, which is dangerous of corneal edema, lipid deposition, and opacification. Moreover, as known, corneal neovascularization (CNV; preexisting or postoperative) may contribute to immune response against the transplant. Suppression of neovascularization is able to decrease the risk of corneal transplant rejection. In order to identify the principal strategy for struggling against CNV, we should first get a better understanding of its etiology, pathogenesis, and role in transplant immunity as well as mechanisms of action of available treatment methods.

[Hypothesis of immune privilege of the cornea and pathophysiology of graft rejection]. / Gipoteza immunnoi privilegii rogovitsy i patofiziologiia ottorzheniia keratotransplantata.

Transplantation of donated cornea is a radical and pathogenetically oriented measure of rehabilitation for patients with corneal blindness. Unlike other transplantation surgeries, keratoplasty is usually done without tissue typing and systemic immunosuppression. Even so, in the absence of risk factors, grafts can remain clear in as many as 90% of cases. The phenomenon is explained by immune privilege of the cornea. The hypothesis of immune privilege comprises several interrelated mechanisms that ensure long-lasting transparency of the graft. These include transfer limits of immunogenic stimuli to peripheral lymphoid tissues, deviation of the immune response, and neutralization of immune effector elements within the host-graft interface by immunosuppressive ocular environment. A change in any of the said components leads to loss of the immune-privilege status of the cornea, thus, significantly increasing the risk of graft rejection. We know several stages of the response activation cascade in graft rejection that can be influenced therapeutically, namely, antigen absorption, processing, and presentation as well as T-cell expansion and cellular inflow to the eye. The first two stages take place in the eye itself and are susceptible to instillation drugs and gene therapy. New highly selective medications aimed at specific signals from the immune cells and their pathways may be able to help restore the immune privilege of the cornea and improve the results of optical and reconstructive surgeries in high-risk patients.

[Risk factors, clinical presentations, prevention, and treatment of corneal graft rejection]. / Faktory riska, klinicheskie proiavleniia, metody profilaktiki i lecheniia reaktsii ottorzheniia transplantata rogovitsy.

Corneal transplantation is the most common and successful type of allotransplantation surgery. Post-transplant immune response in keratoplasty is less pronounced than that in other transplantation procedures, which is accounted for by anatomical features of the cornea and, also, its low antigenic potential and active immunosuppression. However, the immune privilege of the cornea can be violated by neovascularization, inflammation, or trauma. Patients who require keratoplasty to restore their sight and whose immune privilege is disturbed, fall into a high-risk group and are likely to demonstrate tissue incompatibility and non-transparent engraftment. Two approaches exist as to how graft rejection can be prevented. One of them involves induction of donor-specific tolerance, the other - non-specific suppression of the recipient's immune response. To avoid tissue incompatibility, measures can be taken to restore the immune privilege of the cornea as well as to induce antigen-specific tolerance, which is considered a promising, thought yet experimental, area of modern transplantology. In clinical practice, one pays most attention to improvement of non-specific immune suppression methods based on interfering in the metabolism of immunocompetent cells. Thus, timely prescriptions and proper immunosuppressive tactics with account to possible risk factors determine the outcome in high-risk patients undergoing corneal transplantation surgery.