Excimer laser-assisted phototherapeutic keratectomies combined to EDTA chelation for the treatment of calcific band keratopathy.

INTRODUCTION: Calcific band keratopathy (CBK) is a relatively common chronic corneal degeneration and various forms of treatment are mentioned in the literature. CASES DESCRIPTION: Two patients (89 and 37 yo, respectively) affected by diffuse long-standing CBK in one eye and complaining of ocular pain, foreign body sensation and decreased visual acuity are reported. An ethylenediaminetetraacetic acid (EDTA) application on the ocular surface was performed associated with a customized no-touch transepithelial phototherapeutic corneal remodeling in one patient and a standard phototherapeutic keratectomy (PTK) in the second patient. Corneal transparency progressively improved in both cases since the early follow-up visits and the cornea became clear 2 weeks after surgery. In both cases, a significant reduction of ocular discomfort was reported. CONCLUSIONS: Combining EDTA chelation and excimer laser-assisted PTK represents an useful treatment of band keratopathy even in challenging cases and may help regularize corneal surface and improve corneal clarity.

TNF-α Inhibitors for the Management of Intractable Corneal Melt: Report of Three Cases and Review of the Literature.

OBJECTIVE: To report three consecutive cases with noninfectious corneal melting, whose disease progression could only be halted with tumor necrosis-α (TNF-α) inhibitor infusion, with a review of the relevant literature. MATERIALS AND METHODS: Patients with toxic epidermal necrolysis, severe alkaline burn, and Sjögren syndrome had experienced severe corneal melting following penetrating keratoplasty, Boston type 1 keratoprosthesis implantation or spontaneously, respectively. Topical autologous serum eye-drops, medroxyprogesterone, and acetylcysteine formulations; frequent nonpreserved lubrication; systemic tetracyclines and vitamin-C supplements; topical and systemic steroids and steroid-sparing agents; surgical approaches including amniotic membrane transplantation, tectonic graft surgery; and tarsorraphy failed to alter the disease courses. RESULTS: Upon consultation with the rheumatology clinic, TNF-α inhibitor infliximab (Remicade; Centocor Ortho Biotech Inc, Horsham, PA) 5 mg/kg infusion was planned for each patient. After 0-, 2-, and 6-week doses, monthly infusion at the same dose was maintained for 12 months because of severe and intractable course of their diseases. Each case showed dramatic improvements in corneal melts; and sterile vitritis in the eye with Boston keratoprosthesis responded, as well. CONCLUSIONS: Inhibiting TNF-α-mediated expression of matrix metalloproteinases responsible for collagen breakdown should be considered in refractory cases, as a means of globe salvage.

Magnetic Human Corneal Endothelial Cell Transplant: Delivery, Retention, and Short-Term Efficacy.

Purpose: Corneal endothelial dysfunction leads to corneal edema, pain, and vision loss. Adequate animal models are needed to study the safety and efficacy of novel cell therapies as an alternative to corneal transplantation. Methods: Primary human corneal endothelial cells (HCECs) were isolated from cadaveric donor corneas, expanded in vitro, transduced to express green fluorescent protein (GFP), loaded with superparamagnetic nanoparticles, and injected into the anterior chamber of adult rabbits immediately after endothelial cell or Descemet's membrane stripping. The same volume of balanced salt solution plus (BSS+) was injected in control eyes. We compared different models for inducing corneal edema in rabbits, and examined the ability of transplanted HCECs to reduce corneal edema over time by measuring central corneal thickness and tracking corneal clarity. GFP-positive donor cells were tracked in vivo using optical coherence tomography (OCT) fluorescence angiography module, and the transplanted cells were confirmed by human nuclei immunostaining. Results: Magnetic HCECs integrated onto the recipient corneas with intact Descemet's membrane, and donor identity was confirmed by GFP expression and immunostaining for human nuclei marker. Donor HCECs formed a monolayer on the posterior corneal surface and expressed HCEC functional markers of tight junction formation. No GFP-positive cells were observed in the trabecular meshwork or on the iris, and intraocular pressure remained stable through the length of the study. Conclusions: Our results demonstrate magnetic cell-based therapy efficiently delivers HCECs to restore corneal transparency without detectable toxicity or adverse effect on intraocular pressure. Magnetic delivery of HCECs may enhance corneal function and should be explored further for human therapies.

Successful management of epithelial ingrowth after sequential intracameral 5-fluorouracil and Descemet-stripping automated endothelial keratoplasty.

To describe the successful treatment of epithelial ingrowth using combined surgical excision with intracameral adjuvant 5-fluorouracil (5-FU) followed by Descemet-stripping automated endothelial keratoplasty (DSAEK). A 71-year-old man presented with epithelial ingrowth after clear corneal phacoemulsification. He underwent surgical excision of the membrane together with pars plana vitrectomy, air fluid exchange, and intracameral 5-FU. This treatment resulted in corneal decompensation for which DSAEK was performed 6 months later. Despite interface haze, the postoperative corrected distance visual acuity returned to 20/40 three months after DSAEK. There was no clinical evidence of recurrence of the epithelial ingrowth 9 months after the surgical removal. Intracameral 5-FU can be used in conjunction with surgical excision and subsequent DSAEK to successfully treat epithelial ingrowth.

Descemet's Membrane Biomimetic Microtopography Differentiates Human Mesenchymal Stem Cells Into Corneal Endothelial-Like Cells.

PURPOSE: Loss of corneal endothelial cells (CECs) bears disastrous consequences for the patient, including corneal clouding and blindness. Corneal transplantation is currently the only therapy for severe corneal disorders. However, the worldwide shortages of corneal donor material generate a strong demand for personalized stem cell-based alternative therapies. Because human mesenchymal stem cells are known to be sensitive to their mechanical environments, we investigated the mechanotransductive potential of Descemet membrane-like microtopography (DLT) to differentiate human mesenchymal stem cells into CEC-like cells. METHODS: Master molds with inverted DLT were produced by 2-photon lithography (2-PL). To measure the mechanotransductive potential of DLT, mesenchymal stem cells were cultivated on silicone or collagen imprints with DLT. Changes in morphology were imaged, and changes in gene expression of CEC typical genes such as zonula occludens (ZO-1), sodium/potassium (Na/K)-ATPase, paired-like homeodomain 2 (PITX2), and collagen 8 (COL-8) were measured with real-time polymerase chain reaction. At least immunofluorescence analysis has been conducted to confirm gene data on the protein level. RESULTS: Adhesion of MSCs to DLT molded in silicone and particularly in collagen initiates polygonal morphology and monolayer formation and enhances not only transcription of CEC typical genes such as ZO-1, Na/K-ATPase, PITX2, and COL-8 but also expression of the corresponding proteins. CONCLUSIONS: Artificial reproduction of Descemet membrane with respect to topography and similar stiffness offers a potential innovative way to bioengineer a functional CEC monolayer from autologous stem cells.

[The Boston keratoprosthesis in the management of corneal blindness: Indications and limitations]. / La kératoprothèse de Boston dans la prise en charge de la cécité cornéenne : intérêts et limites.

INTRODUCTION: Keratoprostheses offer a therapeutic alternative to patients with bilateral corneal blindness who cannot undergo corneal allograft. The goal of this work was to evaluate the indications and limitations of Boston keratoprosthesis. MATERIALS AND METHODS: Seven patients underwent unilateral implantation of a Boston type I keratoprosthesis between December 2012 and November 2016. The following data were collected: surgical indication, preoperative visual acuity, postoperative visual acuity at D1, D7, D30, 6 months and 12 months, complications and postoperative treatment. RESULTS: The mean age of implantation was 58.7±23.4 years. The surgical indications included 1 case of congenital bilateral aniridia, 2 cases of chemical burn and 4 graft decompensations after multiple keratoplasties. Preoperative visual acuity was limited to "light perception" in 6 cases and "hand motion" in one case. A gain in visual acuity was observed in 4 patients, which corresponded to a mean gain of 1.53 logMAR at last follow-up. Postoperative visual acuity averaged 2.33 logMAR. All patients experienced an improvement in their quality of life and independence. DISCUSSION: Patients should be selected carefully, favoring patients with a remaining functional potential and able to engage in close postoperative follow-up, in order to ensure the best possible treatment success. CONCLUSION: Boston keratoprosthesis provides improved vision and improved quality of life for patients suffering from bilateral corneal blindness.

Combined transepithelial phototherapeutic keratectomy and corneal collagen cross-linking for corneal ectasia after small-incision lenticule extraction-preoperative and 3-year postoperative results: a case report.

BACKGROUND: Corneal ectasia after small-incision lenticule extraction (SMILE) is uncommon. To our knowledge, this is the first report of 3-year results of combined phototherapeutic keratectomy (PTK) and corneal collagen cross-linking (CXL) for corneal ectasia after SMILE. CASE PRESENTATION: Herein, we describe a case of prominent corneal ectasia after SMILE treated with PTK combined with CXL 3 years ago. After surgery, maximum corneal keratometry, mean corneal keratometry, spherical equivalent and uncorrected distance visual acuity were significantly improved at follow-up intervals. CONCLUSIONS: Transepithelial PTK combined with CXL for corneal ectasia after SMILE may be an effective and safe treatment in the long term.

Techniques for Learning Descemet Membrane Endothelial Keratoplasty for Eyes of Asian Patients With Shallow Anterior Chamber.

PURPOSE: To describe several essential surgical techniques that overcome difficulties in performing Descemet membrane endothelial keratoplasty (DMEK) for inexperienced surgeons, especially those who perform DMEK on eyes of Asian patients. METHODS: Nine eyes of 9 Asian patients with bullous keratopathy who underwent DMEK were analyzed retrospectively. All patients were given a diuretic such as D-mannitol or acetazolamide shortly before surgery, with retrobulbar anesthesia and a Nadbath facial nerve block. Core vitrectomy before DMEK was performed in several cases in which a high vitreous pressure during surgery was predicted. The donor graft was stained with trypan blue, and a 25-G anterior chamber maintenance cannula was used to maintain the anterior chamber depth during graft insertion in all eyes. RESULTS: The cornea became clear in all eyes. The best spectacle-corrected visual acuity had improved significantly 6 months after the surgery compared with preoperative values (P = 0.026). The corneal endothelial cell density was 1371 cells per square millimeter at postoperative 6 months. CONCLUSIONS: Although DMEK is technically difficult, especially for inexperienced surgeons who operate on eyes of Asian patients, controlling anterior chamber pressure using various manipulations may help to prevent iatrogenic primary graft failure and lead to successful DMEK.

Excimer laser mushroom penetrating keratoplasty: new technique.

PURPOSE: To evaluate retrospectively the outcomes of 15 consecutive mushroom-shaped penetrating keratoplasties performed by using excimer laser for both the recipient bed and the fresh donor corneas. METHODS: Fifteen eyes of 14 patients who underwent excimer laser mushroom-shaped penetrating keratoplasty from October 13, 2010, to October 14, 2011, were included in our retrospective study. Eight were men and 6 were women, with a mean age of 31.45 ± 6.52 (range 27-65) years. Eleven (73.3%) had postinfective central deep corneal scar; 4 (26.7%) had severe keratoconus with Descemet opacity. RESULTS: The mean follow-up was 11.9 ± 2.7 months. The mean preoperative best-corrected visual acuity (BCVA) was 0.15 ± 0.16; the postoperative BCVA was 0.69 ± 0.24 after 12 months with a mean refractive astigmatism of 1.8 ± 1.1 D. The mean preoperative endothelial cell count of the donor corneas was 2297.0 ± 189.7 cells/mm²; after 12 months, it was 1906.5 ± 165.8 with a decrease of 17.0%. No intraoperative complications occurred. CONCLUSIONS: Our results showed that excimer laser mushroom penetrating keratoplasty is safe. Furthermore, it does not appear to influence the visual outcomes of the penetrating keratoplasty surgery. This technique is useful for those who use an excimer laser.

Long-term outcomes after adjunctive topical 5-flurouracil or mitomycin C for the treatment of surgically excised, localized ocular surface squamous neoplasia.

BACKGROUND: To report rates of recurrence and complications of localized ocular surface squamous neoplasia treated with 5-fluorouracil or mitomycin C as adjunctive treatment to surgical excision. DESIGN: Long-term follow up of two prospective, non-comparative interventional case series. PARTICIPANTS: One hundred fifty-three eyes with histologically confirmed localized, non-invasive ocular surface squamous neoplasia. 89 eyes were treated with adjuvant 5-fluorouracil and 64 eyes were treated with adjuvant mitomycin C. METHODS: Following surgical excision±cryotherapy patients received topical 5-fluorouracil 1% four times daily for two weeks or topical mitomycin C 0.04% four times daily for two to three 1-week cycles. MAIN OUTCOME MEASURES: Ocular surface squamous neoplasia recurrence, complications of therapy and compliance. RESULTS: Median follow up was 33.6 (range 12-84) months and 57.9 (range 12-160) months in 5-fluorouracil and mitomycin C groups, respectively. There was one recurrence in the 5-fluorouracil group and no recurrences in the mitomycin C group. Side-effects occurred in 69% of 5-fluorouracil patients and 41% of mitomycin C patients. Five patients (6%) required intervention for treatment-related side-effects in the 5-fluorouracil group versus 11 (17%) in the mitomycin C group. No vision-threatening complications were noted. CONCLUSIONS: Long-term recurrence of localised ocular surface squamous neoplasia is rare when topical 5-fluorouracil or mitomycin C are used as adjunctive treatment to surgical excision. While side-effects are common, the majority are transient and rarely limit compliance.

Eye drops preservative as the cause of corneal band keratopathy in long-term pilocarpine hydrochloride treatment.

The aim is to present a patient with severe bilateral corneal complications after long-term antiglaucoma treatment with 1% pilocarpine hydrochloride (Pilokarpin, Pliva, Zagreb, Croatia) and its management. A patient with narrow-angle glaucoma treated with 1% topical pilocarpine hydrochloride eye drops for the last twenty years complained of impaired vision, intermittent visual haloes and eye redness. Ophthalmologic examination showed bilateral band keratopathy, peripheral laser iridotomy, medicamentous myosis, brown nuclear cataract, and synchysis scintillans of his right eye. Band keratopathy was thought to have resulted from the presence of the preservative phenylmercuric nitrate in the pilocarpine hydrochloride eye drops. Treatment of the patient consisted of two separate procedures for both eyes, i.e. phaco trabeculectomy and six months later corneal procedure including abrasion of corneal epithelium followed by removal of the superficial stromal calcium deposits by means of a 3.75% ethylenediaminetetraacetic (EDTA) solution. After phaco trabeculectomy, visual acuity was 0.8 on both eyes. Bilateral visual improvement with visual acuity 1.0 was recorded after corneal treatment with EDTA. In conclusion, one must be aware of preservative complications in long-term topical use, such as band keratopathy that can be visually incapacitating. Surgical treatment using EDTA is safe and effective treatment for band keratopathy.

Predictors of ocular surface squamous neoplasia recurrence after excisional surgery.

PURPOSE: To identify predictors of ocular surface squamous neoplasm (OSSN) recurrence after operative resection. DESIGN: Retrospective case series. PARTICIPANTS: Three hundred eighty-nine consecutive patients who underwent excisional biopsy for OSSN lesions at the Bascom Palmer Eye Institute from January 1, 2001, to September 20, 2010. METHODS: Review of pathology records and patient charts. MAIN OUTCOME MEASURES: Identification of factors predictive of OSSN recurrence. RESULTS: Of 389 excised OSSN lesions, 44 recurred during follow-up. The 1-year recurrence rate was 10% and the 5-year recurrence rate was 21%, with a mean time to recurrence in those with a recurrence of 2.5 years (standard deviation, 3.4). Using the American Joint Committee on Cancer (AJCC) clinical staging system, T3 and T2 lesions portended a higher risk of recurrence compared with T1 (T2/T1 hazard ratio [HR], 2.05 [P = 0.04]; T3/T1 HR, 2.31 [P = 0.07]). In addition, a location characteristic that increased the risk of tumor recurrence was tarsal involvement (AJCC T3 stage lesion; HR, 4.12; P = 0.007). Nasal location was associated with a decreased risk of tumor recurrence (HR, 0.41; P = 0.008). Pathologic characteristics significantly associated with tumor recurrence were the presence of positive margins (HR, 2.73; P = 0.008) and higher grade lesions (carcinoma in situ and squamous cell carcinoma versus dysplasia; HR, 2.55; P = 0.02). Treatment with adjuvant cryotherapy significantly decreased the risk of tumor recurrence (HR, 0.51; P = 0.03). In those patients with positive margins, the use of postoperative topical interferon therapy lowered the recurrence rate to a level similar to that of patients with negative margins. CONCLUSIONS: Certain patient and tumor factors are associated with a higher risk of OSSN recurrence after operative excision, such as tarsal tumor location and positive surgical margins. Postoperative adjuvant therapy should be considered in patients with high-risk OSSN characteristics.

Photochemical tissue bonding: a potential strategy for treating limbal stem cell deficiency.

BACKGROUND AND OBJECTIVE: To determine the feasibility of attaching human amniotic membrane (HAM), pre-cultured with limbal stem cells (LSCs), to cornea using a novel, light-activated tissue bonding method. MATERIALS AND METHODS: LSCs were isolated from rabbit eyes, and then cultured on de-epithelialized HAM to create grafts (HAM/LSC). These were then transplanted onto rabbit eyes with surgically created limbal stem cell deficiency (LSCD). The grafts were secured either by sutures or by a light-activated method called photochemical tissue bonding (PTB). Outcomes included corneal opacity, inflammation, neovascularization, and collagen alignment. RESULTS: The isolated and cultured cells were verified to be LSCs based on their K19+/intergrin ß1+/P63+/K3 profile. Securing the HAM/LSC graft with PTB provided better outcomes. At 28 days post-surgery, the corneal opacity scores were significantly lower after securing the graft with PTB compared with suture attachment (0.8 ± 0.5 vs. 1.8 ± 0.5, P < 0.01). Similarly, neovascularization scores were lower after PTB (0.8 ± 0.5 vs. 1.5 ± 0.6, P < 0.01). Quantification of MPO and CD31 levels from immunofluorecent staining indicated that PTB stimulated less neutrophil infiltration (5.3 ± 2.2 vs. 13.3 ± 3.1, P < 0.01) and less new blood vessels formation (2.0 ± 0.8 vs. 6.3 ± 1.3, P < 0.01) at the wound site. The collagen alignment in PTB-treated corneas, as shown by immunofluorescence and second harmonic generation image, was better organized in the PTB-treated group than in the suture group. CONCLUSION: Bonding LSC grafts with PTB produced improved outcomes compared to suture attachment. This light-activated method is a promising modality for treating patients with LSCD.

[Limbal stem cell deficiency following multiple intravitreal injections]. / Insuficiencia limbar secundaria a múltiples inyecciones intravítreas.

CASE REPORT: A 68 year-old male with idiopathic choroidal polypoidal vasculopathy received seven intravitreal injections of bevacizumab in the supero-nasal quadrant. He later developed a localized limbal stem cell deficiency which required limbal transplantation from the same eye. Two months after surgery, a slight improvement of visual acuity was noted, along with an intact ocular surface, clear cornea and decreased inflammation. DISCUSSION: Repeated surgical trauma on the limbus and surrounding areas may damage the limbal stem cells, giving rise to a corneal epitheliopathy due to iatrogenic limbal deficiency. Repeated intravitreal injections may be considered as one of the possible causes.

Comparison of candidate materials for a synthetic osteo-odonto keratoprosthesis device.

PURPOSE: Osteo-odonto keratoprosthesis is one of the most successful forms of keratoprosthesis surgery for end-stage corneal and ocular surface disease. There is a lack of detailed comparison studies on the biocompatibilities of different materials used in keratoprosthesis. The aim of this investigation was to compare synthetic bioinert materials used for keratoprosthesis surgery with hydroxyapatite (HA) as a reference. METHODS: Test materials were sintered titanium oxide (TiO(2)), aluminum oxide (Al(2)O(3)), and yttria-stabilized zirconia (YSZ) with density >95%. Bacterial adhesion on the substrates was evaluated using scanning electron microscopy and the spread plate method. Surface properties of the implant discs were scanned using optical microscopy. Human keratocyte attachment and proliferation rates were assessed by cell counting and MTT assay at different time points. Morphologic analysis and immunoblotting were used to evaluate focal adhesion formation, whereas cell adhesion force was measured with a multimode atomic force microscope. RESULTS: The authors found that bacterial adhesion on the TiO(2), Al(2)O(3), and YSZ surfaces were lower than that on HA substrates. TiO(2) significantly promoted keratocyte proliferation and viability compared with HA, Al(2)O(3,) and YSZ. Immunofluorescent imaging analyses, immunoblotting, and atomic force microscope measurement revealed that TiO(2) surfaces enhanced cell spreading and cell adhesion compared with HA and Al(2)O(3). CONCLUSIONS: TiO(2) is the most suitable replacement candidate for use as skirt material because it enhanced cell functions and reduced bacterial adhesion. This would, in turn, enhance tissue integration and reduce device failure rates during keratoprosthesis surgery.

From hair to cornea: toward the therapeutic use of hair follicle-derived stem cells in the treatment of limbal stem cell deficiency.

Limbal stem cell deficiency (LSCD) leads to severe ocular surface abnormalities that can result in the loss of vision. The most successful therapy currently being used is transplantation of limbal epithelial cell sheets cultivated from a limbal biopsy obtained from the patient's healthy, contralateral eye or cadaveric tissue. In this study, we investigated the therapeutic potential of murine vibrissae hair follicle bulge-derived stem cells (HFSCs) as an autologous stem cell (SC) source for ocular surface reconstruction in patients bilaterally affected by LSCD. This study is an expansion of our previously published work showing transdifferentiation of HFSCs into cells of a corneal epithelial phenotype in an in vitro system. In this study, we used a transgenic mouse model, K12(rtTA/rtTA) /tetO-cre/ROSA(mTmG) , which allows for HFSCs to change color, from red to green, once differentiation to corneal epithelial cells occurs and Krt12, the corneal epithelial-specific differentiation marker, is expressed. HFSCs were isolated from transgenic mice, amplified by clonal expansion on a 3T3 feeder layer, and transplanted on a fibrin carrier to the eye of LSCD wild-type mice (n = 31). The HFSC transplant was able to reconstruct the ocular surface in 80% of the transplanted animals; differentiating into cells with a corneal epithelial phenotype, expressing Krt12, and repopulating the corneal SC pool while suppressing vascularization and conjunctival ingrowth. These data highlight the therapeutic properties of using HFSC to treat LSCD in a mouse model while demonstrating a strong translational potential and points to the niche as a key factor for determining stem cell differentiation.

Flap lift and repair of postoperative laser in situ keratomileusis complications at the slitlamp.

UNLABELLED: We describe a technique to treat flap complications after laser in situ keratomileusis while seated at the slitlamp biomicroscope. After topical anesthesia is applied to the cornea, a blunt corneal spatula is used to reflect the flap only to the extent necessary for epithelial debridement. A corneal rake or spatula is then used to remove retained epithelial cells from the stromal bed and underside of the flap. The epithelium is then debrided 1.0 mm to 2.0 mm outside the flap gutter. The increased depth perception with a slit beam greatly improves visualization and identification of the presence of residual epithelial cells or leftover debris after scraping. The slit beam also aids in proper repositioning of the flap after the procedure. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

[Vision jeopardizing xerophthalmia in Denmark]. / Synstruende xeroftalmi i Danmark.

A 54-year-old alcoholic was admitted with keratomalacia in 2001. The right cornea had an ulceration and the left cornea had stromal necrosis and a perforation. Serum retinol and serum betacaroten were extremely low. Treatment consisted of high-dose retinol and left sided cornea transplantation. The right eye healed with little scarring, vision: 0.5. The left eye was stabilized after a second cornea transplantation and covering with conjunctiva, vision: hand movement at a distance of 1 m. This proves the existence of symptomatic vitamin A deficiency among socially exposed subjects in Denmark.