ABSTRACT
Fungal keratitis is a devastating and difficult-to-treat ocular infection with high morbidity. Understanding geographic microbiological and clinical trends helps to guide rapid and effective treatment. We therefore report the characteristics and outcomes of fungal keratitis in Toronto,ON Canada, over a 20-year period. An electronic search of microbiology records at University Health Network, Toronto, ON, Canada identified all patients with positive corneal fungal culture over a 20-year period seen at our tertiary referral cornea practice. Review of corresponding patient charts identified demographic and microbiological details, clinical course, treatment regimen, and final outcomes associated with each episode of culture-positive fungal keratitis. A total of 46 patients with 51 discrete fungal keratitis episodes were included. Five patients experienced recurrent fungal keratitis. Candida species accounted for 60.8% of positive fungal cultures, followed by Filamentous species at 35.3%. Preferred initial anti-fungal treatment was topical amphotericin at 36.7% followed by topical voriconazole at 32.6%. Surgical intervention was required in 48.9% with therapeutic penetrating keratoplasty being the most common procedure (22.4%). Final visual acuity (VA) of <20/200 was attributed to 58% of patients in this study. Risk factors for poor outcomes included poor VA, topical steroid use at presentation, Candida involvement, history of ocular surface disease, organic ocular trauma, or prior corneal transplantation. Candida is the most frequent keratomycotic pathogen in Toronto. Risk factors for poor visual outcome include prior corneal transplantation, ocular surface disease/trauma, or pre-existing topical steroid use. Early suspicion, diagnosis and treatment are paramount for best clinical outcomes. LAY SUMMARY: Fungal keratitis can cause severe vision loss without effective treatment. In Toronto, Candida had been the most common species over a 20-year period. Poor clinical outcome was associated with low presenting visual acuity, previous corneal transplant, topical steroid use, trauma, and Candida involvement.
Subject(s)
Corneal Ulcer , Eye Infections, Fungal , Animals , Antifungal Agents/therapeutic use , Candida , Cornea/microbiology , Corneal Ulcer/microbiology , Corneal Ulcer/veterinary , Eye Infections, Fungal/diagnosis , Eye Infections, Fungal/drug therapy , Eye Infections, Fungal/epidemiology , Eye Infections, Fungal/veterinary , Humans , Retrospective Studies , Voriconazole/therapeutic useABSTRACT
OBJECTIVES: To assess outcomes of limbal stem cell deficiency (LSCD) in patients treated with Prosthetic Replacement of the Ocular Surface Ecosystem (PROSE). METHODS: Retrospective case series. Patients with LSCD who received PROSE treatment were included. Data including best-corrected visual acuity (BCVA) and LSCD staging before and after PROSE dispensing were collected to characterize each case. RESULTS: Five eyes of four patients were included. All patients were female, with an age range of 21 to 80 years. Each patient received a PROSE device with diameters ranging from 16 to 18.5 mm. Follow-up ranged from 11 to 29 months. Tolerated wear times ranged from 3.5 to 10 hr daily. Four eyes showed improved BCVA and unchanged LSCD staging as per the global consensus after PROSE treatment. Three of these eyes had stage 3 and one had stage 1C LSCD at diagnosis. The fifth eye had worse BCVA and recurrence of stage 3 LSCD post-living-related conjunctival limbal allograft transplant despite PROSE treatment. CONCLUSIONS: Prosthetic Replacement of the Ocular Surface Ecosystem may be a viable treatment for LSCD, including severe cases, because it can provide symptom relief and improve vision. Its customizability, as demonstrated in this study, is beneficial for troubleshooting issues with fitting. Future studies are needed to further assess PROSE as treatment for LSCD.
Subject(s)
Corneal Diseases , Limbus Corneae , Humans , Female , Young Adult , Adult , Middle Aged , Aged , Aged, 80 and over , Male , Retrospective Studies , Ecosystem , Visual Acuity , Follow-Up Studies , Corneal Diseases/surgery , Corneal Diseases/diagnosis , Stem CellsABSTRACT
OBJECTIVES: To assess outcomes of the Prosthetic Replacement of the Ocular Surface Ecosystem (PROSE) treatment in patients with advanced Terrien marginal degeneration (TMD). METHODS: This is a retrospective case series of patients with advanced TMD who were assessed and fit with customized PROSE lenses. Data were collected on PROSE fitting details including visual acuity (VA) before and after PROSE, slit-lamp findings, and corneal tomography scans. RESULTS: Six eyes in four patients were included. All patients attempted at least one other contact lens (CL) modality before PROSE. Some patients had corneal comorbidities such as pseudopterygium and pseudobleb that contributed to intolerance to previous lenses and warranted extra considerations in the fitting process. With PROSE, VA improved in all six eyes. Patients with structural corneal comorbidities achieved improved vision, comfort, and lens tolerance with PROSE. Two eyes had noncorneal ocular comorbidities that limited PROSE efficacy. Another eye discontinued PROSE wear because of limbal stem-cell disease progression necessitating a limbal stem-cell transplant. CONCLUSIONS: PROSE treatment can be an effective option to improve vision and comfort for patients with advanced TMD who are intolerant to first-line therapeutic CL modalities, even in the presence of other corneal comorbidities.
Subject(s)
Corneal Diseases , Corneal Dystrophies, Hereditary , Humans , Sclera , Retrospective Studies , Ecosystem , Prosthesis Fitting/adverse effects , Corneal Diseases/surgery , Corneal Diseases/etiologyABSTRACT
OBJECTIVES: To investigate underlying diagnoses and outcomes of patients undergoing Prosthetic Replacement of the Ocular Surface Ecosystem (PROSE) treatment at the first Canadian PROSE center. METHODS: A retrospective chart review was conducted on patients referred for PROSE treatment and fitted with PROSE devices from 2018 to 2020. Data were collected on diagnoses, presenting symptoms, previous lens modalities attempted, best-corrected visual acuities (BCVAs) pre-PROSE and post-PROSE, daily wear time, and failure rates. Best-corrected visual acuities pre-PROSE and post-PROSE were compared to evaluate visual improvement. RESULTS: In total, 78 patients (126 eyes) were analyzed. The most common diagnoses were keratoconus (n=39 eyes) and postcorneal graft (n=15) in the distorted cornea group, and limbal stem cell deficiency (n=17) and graft versus host disease (n=15) in the ocular surface disease (OSD) group. Most frequent symptoms included blur, photophobia, and pain. Most common lens modalities attempted pre-PROSE were conventional scleral lenses and glasses. The overall mean BCVA improvement was 0.40 logarithm of the minimal angle of resolution (logMAR) (4-lines Snellen) (P<0.0001). Best-corrected visual acuities improvement in the distorted cornea group (0.52 logMAR, 5-lines) was significantly greater than in the OSD group (0.29 logMAR, 3-lines) (P=0.004). CONCLUSIONS: Prosthetic replacement of the ocular surface ecosystem treatment can provide significant visual improvement for patients with distorted corneal surfaces and OSDs who failed other lens modalities.
Subject(s)
Contact Lenses , Corneal Diseases , Keratoconus , Canada , Corneal Diseases/surgery , Ecosystem , Humans , Retrospective Studies , ScleraABSTRACT
The purpose of this study is to determine the effect on endothelial cell density and morphology of combined subconjunctival and intracorneal injection of bevacizumab for the treatment of corneal neovascularization (NV). The charts and specular microscopy images of ten consecutive patients with corneal NV, who received combined subconjunctival+intracorneal injections of bevacizumab were reviewed. Patients received three injections of bevacizumab 25 mg/mL (1.25 mg/0.05 mL subconjunctival and 1.25 mg/0.05 mL intrastromal) 4-6 weeks apart. Endothelial cell counts (ECCs) and morphological changes were assessed by non-contact specular microscopy performed at baseline, 1 month after each injection and at 3 and 6 months after the last injection. There were no significant changes in ECCs (p = 0.663), coefficient of variation (p = 0.076), percentage of hexagonal cells (p = 0.931) or mean corneal thickness (p = 0.462) from pre-injection values to the 6-month follow-up values. There were no intraoperative or postoperative complications. In our series, the use of combined subconjunctival and intracorneal bevacizumab did not cause any decrease in ECCs or morphological alterations up to 6 months after the last of three injections. Further studies are required to confirm long-term safety in a larger sample population with longer follow-up, as well as the ideal dose, route of administration and frequency of bevacizumab administration.
Subject(s)
Angiogenesis Inhibitors/adverse effects , Antibodies, Monoclonal, Humanized/adverse effects , Corneal Neovascularization/drug therapy , Endothelium, Corneal/pathology , Adult , Aged , Aged, 80 and over , Analysis of Variance , Bevacizumab , Endothelial Cells/cytology , Female , Humans , Injections, Intraocular , Male , Middle Aged , Young AdultABSTRACT
PURPOSE: To compare long-term outcomes of simultaneous accelerated corneal crosslinking (CXL) with intrastromal corneal ring segments (CXL-ICRS) with simultaneous accelerated CXL with topography-guided photorefractive keratectomy (CXL-TG-PRK) in progressive keratoconus (KC). SETTING: Kensington Eye Institute and Bochner Eye Institute, Toronto, Canada. DESIGN: Prospective nonrandomized interventional study. METHODS: The change in visual and topographical outcomes of CXL-ICRS and CXL-TG-PRK 4 to 5 years postoperatively were compared using linear regression models adjusted for preoperative corrected distance visual acuity (CDVA) and maximum keratometry (Kmax). RESULTS: 57 eyes of 43 patients with progressive KC who underwent simultaneous accelerated (9 mW/cm 2 , 10 minutes) CXL-ICRS (n = 32) and CXL-TG-PRK (n = 25) were included. Mean follow-up duration was 51.28 (9.58) and 54.57 (5.81) months for the CXL-ICRS and CXL-TG-PRK groups, respectively. Initial mean Kmax was higher in the CXL-ICRS group compared with the CXL-TG-PRK group (60.68 ± 6.81 diopters [D] vs 57.15 ± 4.19 D, P = .02). At the last follow-up, change (improvement) in logMAR uncorrected distance visual acuity (UDVA) compared with that preoperatively was significant with CXL-ICRS (-0.31 ± 0.27, P < .001, which is equivalent to approximately 3 lines) and not significant with CXL-TG-PRK (-0.06 ± 0.42, P = .43). The logMAR CDVA improved significantly with CXL-ICRS (-0.22 ± 0.20, P < .001), but not with CXL-TG-PRK (-0.05 ± 0.22, P = .25). Adjusting for baseline Kmax and CDVA, the improvement in UDVA was significantly greater with CXL-ICRS than with CXL-TG-PRK (-0.27, 95% CI, 0.06-0.47, P = .01). Improvement in CDVA was not significantly different. CONCLUSIONS: In this cohort of progressive KC with long-term follow-up, UDVA showed more improvement with accelerated CXL-ICRS than with CXL-TG-PRK.
Subject(s)
Keratoconus , Refraction, Ocular , Humans , Photosensitizing Agents/therapeutic use , Riboflavin/therapeutic use , Prospective Studies , Combined Modality Therapy , Corneal Stroma/surgery , Corneal Topography , Keratoconus/drug therapy , Keratoconus/surgery , Cross-Linking Reagents/therapeutic useABSTRACT
PURPOSE: The purpose of this study was to evaluate 5-year safety and efficacy outcomes of femtosecond-enabled Descemet membrane endothelial keratoplasty (F-DMEK) in patients with Fuchs' endothelial dystrophy (FED). METHODS: This was a retrospective study, including patients with FED and cataract who underwent either F-DMEK (16 eyes of 15 patients) or manual DMEK (M-DMEK) (42 eyes of 37 patients) combined with cataract extraction. Outcome measures included visual acuity, graft detachment, graft survival, and endothelial cell loss. RESULTS: The average follow-up in F-DMEK and M-DMEK was 57.1 ± 12.4 months and 58.5 ± 17.3 months, respectively ( P = 0.757). The rates of primary failure (0% vs. 9.5%, P = 0.567), secondary failure (0% for both), and graft rejection (0% vs. 7.1%, P = 0.533) did not differ significantly between the groups. Improvement in best spectacle-corrected visual acuity was similar in F-DMEK and M-DMEK (0.32 ± 0.27 logarithm of the minimum angle of resolution and 0.35 ± 0.44 logarithm of the minimum angle of resolution, respectively, P = 0.165) and persisted at 2, 3, 4, and 5 years and at the last follow-up. The rates of graft detachment and rebubbling were significantly lower with 6.25% in F-DMEK and 33.3% in M-DMEK ( P = 0.035). Cell-loss rates were lower in F-DMEK compared with M-DMEK throughout the follow-up, significantly so up to 2 years with a difference of 8.6% at 1 year ( P = 0.023), 11.8% at 2 years ( P = 0.021), 7.6% at 3 years ( P = 0.088), 5.8% at 4 years ( P = 0.256), 13.6% at 5 years ( P = 0.169), and 7.1% at the final follow-up ( P = 0.341). CONCLUSIONS: F-DMEK had an excellent safety and efficacy profile which was maintained over 5 years of follow-up. Lower endothelial cell-loss rates in F-DMEK compared with M-DMEK may help extend the duration of graft survival.
Subject(s)
Descemet Stripping Endothelial Keratoplasty , Fuchs' Endothelial Dystrophy , Humans , Descemet Membrane/surgery , Endothelium, Corneal/transplantation , Retrospective Studies , Fuchs' Endothelial Dystrophy/surgery , Lasers , Cell CountABSTRACT
PURPOSE: To report outcomes of keratolimbal allograft (KLAL) compatible for both human leukocyte (HLA) and/or blood type using oral prednisone, mycophenolate, and tacrolimus, with basiliximab if panel reactive antibodies (PRA) are present. Intravenous immunoglobulin (IVIG) was used post-operatively if donor-specific anti-HLA antibodies (DSA) were present. METHODS: Retrospective interventional series of consecutive patients with KLAL for limbal stem cell deficiency (LSCD) from HLA and/or blood type compatible deceased donors with a minimum follow-up time of 12 months. Main outcome measures were ocular surface stability, visual acuity and systemic immunosuppression (SI) adverse events. RESULTS: Eight eyes of eight patients with mean age of 48.6 ± 10.1 years (range 34-65 years) were included. Mean follow-up time was 37.3 ± 22.7 months (range 12-71 months) following KLAL; four (50%) had combined LR-CLAL surgery. The etiologies of LSCD were Stevens-Johnson Syndrome (n = 4/8), aniridia (n = 2/8), chemical injury (n = 1/8) and atopic eye disease (n = 1/8). All patients had PRA present and received basiliximab infusions. 5/8 patients received IVIG based on DSA identified pre-operatively. At last follow-up, 7 eyes (87.5%) had a stable ocular surface; 1 eye (12.5%) developed failure and had keratoprosthesis implantation. There was a significant improvement in visual acuity from 1.65 ± 0.48 to 0.68 ± 0.34 logMAR (p = 0.01). SI was tolerated well with minimal adverse events. CONCLUSIONS: Preliminary outcomes of KLAL with ABO compatible tissue using the Cincinnati protocol, preoperative basiliximab (when PRA present) and post-operative IVIG (when DSA present) are encouraging. This protocol may allow for utilization of deceased donor tissue with results approximating those of living donor tissue transplanted for severe bilateral LSCD.
Subject(s)
Corneal Diseases , Limbus Corneae , Humans , Adult , Middle Aged , Aged , Cornea , Corneal Diseases/surgery , Stem Cell Transplantation/methods , Basiliximab , Retrospective Studies , Immunoglobulins, Intravenous , Limbal Stem Cells , Prostheses and Implants , AllograftsABSTRACT
OBJECTIVE: To compare outcomes of phototherapeutic keratectomy (PTK) versus epithelial debridement combined with anterior stromal puncture (ASP) or diamond burr for the treatment of recurrent corneal erosions (RCES) in a large tertiary centre. METHODS: Patients with a diagnosis of RCES secondary to trauma or epithelial basement membrane dystrophy who underwent a surgical procedure between 2009 and 2019 were included in the study. The following data were collected: demographics, ocular history, prior medical treatment, ocular surgeries, intervention, complete epithelialization at postoperative week 1, recurrences, and complications. Recurrence was defined as either an objective finding of a corneal epithelial defect or symptoms suggestive of recurrent epithelial erosion on history. Recurrence rate and time to epithelialization were compared between groups. RESULTS: A total of 97 eyes (73 patients) were included in the study. Mean patient age was 51 ± 16.1 years, and mean follow-up was 474 days. RCES was secondary to epithelial basement membrane dystrophy in 80% (nâ¯=â¯78 of 97), trauma (15%, nâ¯=â¯15 of 97), or idiopathic (4%, nâ¯=â¯4 of 97). Epithelial debridement with ASP was performed in 34 eyes (35%), diamond burr in 33 eyes (33%), and PTK in 30 eyes (31%). Compared with epithelial debridement with ASP (recurrence 29.4%), the recurrence rate was significantly lower for both the diamond burr (9.1%, pâ¯=â¯0.031) and PTK groups (10%, pâ¯=â¯0.048). The diamond burr and PTK groups also had a significantly higher rate of complete epithelialization at 1 week (p < 0.05). CONCLUSION: Compared with epithelial debridement with ASP, diamond burr and PTK have significantly lower rates of recurrence and time to epithelialization and may be considered first for surgical management of RCES.
Subject(s)
Corneal Diseases , Corneal Dystrophies, Hereditary , Corneal Ulcer , Epithelium, Corneal , Photorefractive Keratectomy , Humans , Adult , Middle Aged , Aged , Debridement/adverse effects , Debridement/methods , Lasers, Excimer/therapeutic use , Neoplasm Recurrence, Local/complications , Neoplasm Recurrence, Local/surgery , Photorefractive Keratectomy/methods , Corneal Dystrophies, Hereditary/diagnosis , Corneal Dystrophies, Hereditary/surgery , Epithelium, Corneal/surgery , Punctures/adverse effects , Recurrence , Corneal Diseases/surgeryABSTRACT
OBJECTIVE: To perform an economic appraisal of the Prosthetic Replacement of Ocular Surface Ecosystem (PROSE; BostonSight, Needham Heights, Mass.) lens in patients with a distorted corneal surface or ocular surface disease in Canada. DESIGN: Retrospective observational cohort study with cost, cost-utility, and benefit-cost analyses. PARTICIPANTS: Patients who received PROSE from the only PROSE clinic in Canada from 2018 to 2020. METHODS: Visual acuity (VA) outcomes of the participants were assessed. Benefits were defined as VA improvements that were converted into utilities and then quality-adjusted life years. Economic values were derived via government statements, clinic financial statements, and published literature. RESULTS: Average best-corrected VA (BCVA) improvement was -0.42 ± 0.41 logMAR (pâ¯=â¯2.68â¯×â¯10-13) or Snellen 20/53 for the overall cohort, -0.51 ± 0.48 (pâ¯=â¯5.42â¯×â¯10-8) or Snellen 20/65 for distorted corneal surface patients, and -0.31 ± 0.30 (pâ¯=â¯1.30â¯×â¯10-7) or Snellen 20/41 for ocular surface disease patients. This corresponded to discounted quality-adjusted life year gains of 0.51, 0.65, and 0.42, respectively, over an estimated 5-year PROSE device lifespan. Average cost to fit a patient with PROSE was USD$5 469.85 (CAD$7 087.28), of which USD$4 971.38 (CAD$6 441.42) was clinic cost and USD$498.47 (CAD$645.87) was patient cost. Cost-utility was USD$10 256.47 (CAD$13 289.31) for the overall cohort, USD$8 439.79 (CAD$10 935.44) for distorted corneal surface patients, and US$13 069.90 (CAD$16 934.67) for ocular surface disease patients. The benefit-cost ratio was 34.4 for all, 43.8 for distorted corneal surface patients, and 28.3 for ocular surface disease patients. CONCLUSIONS: Our economic appraisal demonstrated that PROSE treatment provides a significant, cost-effective benefit to Canadian patients with distorted corneal surfaces and ocular surface diseases. This indicates that PROSE clinics are an efficient investment.
Subject(s)
Corneal Diseases , Ecosystem , Humans , Retrospective Studies , Sclera , Canada , Visual Acuity , Corneal Diseases/surgeryABSTRACT
OBJECTIVE: To describe clinical features and management of toxic keratoconjunctivitis associated with punctal and (or) canaliculus stenosis (toxic soup syndrome). DESIGN: Retrospective observational case series. METHODS: Electronic medical record database search for the keywords "toxic soup syndrome" and retrospective chart review were performed. Thirty-five eyes of 25 patients were seen at a tertiary cornea clinic between January 2017 and December 2021. Sex, age, distance-corrected visual acuity, topical medications, symptoms, clinical signs, and outcomes after medical and surgical interventions were analyzed. The main outcome measured was improvement in ocular surface signs and symptoms after interventions. RESULTS: Overall, 35 eyes of 25 patients with a mean age of 66.8 ± 12.8 years, of which 72% were female, were included. The primary complaint was hyperemia and epiphora in all patients. Rosacea or meibomian gland disease were present in all patients, 7 (28%) had glaucoma, and 7 (28%) developed limbal stem cell deficiency. Twenty-two patients (88%) were using topical medications on presentation. All eyes had either punctal plugs, cauterized puncta, or punctal and (or) canaliculus stenosis. Management of all patients consisted of suspension of all preserved topical medications and institution of some type of anti-inflammatory therapy. Nineteen patients (76%) improved after improvement of lacrimal drainage. One patient with severe resistance in the canaliculus required ongoing preservative-free topical steroids. CONCLUSIONS: Chronic drug-induced or pooled inflammatory mediators causing toxic conjunctivitis may be aggravated by punctal and (or) canaliculus stenosis, leading to toxic soup syndrome. Clearance of punctal obstruction leads to improvement in most patients.
ABSTRACT
OBJECTIVES: To compare outcomes of femtosecond-enabled deep anterior lamellar keratoplasty (FE-DALK) and standard deep anterior lamellar keratoplasty (S-DALK). METHODS: An open label, randomized controlled trial (Kensington Eye Institute, Toronto, ON, Canada) including 100 eyes of 97 participants with either keratoconus or corneal scarring, randomized to either FE-DALK (n = 48) or S-DALK (n = 49). PRIMARY OUTCOMES: postoperative astigmatism and surgically induced corneal astigmatism (SIA) - both at 15 months. SECONDARY OUTCOMES: 6-, 12- and 15-month postoperative uncorrected- and best spectacle-corrected visual acuity, steep and flat keratometry, manifest sphere and astigmatism, rate of conversion to penetrating keratoplasty (PK), big-bubble success, central corneal thickness, endothelial cell count and complications. RESULTS: In intention-to-treat analysis, mean postoperative astigmatism in the FE-DALK (n = 30) and S-DALK (n = 30) groups at 15 months was 7.8 ± 4.4 D and 6.3 ± 5.0 D, respectively (p = 0.282) with an adjusted mean difference of 1.3 D (95% CI -1.08, +3.65). Mean SIA (arithmetic) was 9.2 ± 7.8 and 8.8 ± 5.4 D, respectively (p = 0.838) with a mean difference of 0.4 D (95% CI -3.13, +3.85). In an analysis of successful DALK cases only, mean postoperative astigmatism in the FE-DALK (n = 24) and S-DALK (n = 20) groups at 15 months (after excluding 4 eyes with AEs) was 7.3 ± 4.4 and 6.2 ± 4.9 D, respectively (p = 0.531) with an adjusted mean difference of 0.9 D (95% CI -1.94, +3.71). Mean SIA (arithmetic) was 9.1 ± 7.8 and 7.9 ± 4.6 D, respectively (p = 0.547) with a mean difference of 1.2 D (95% CI -2.70,+5.02). Comparison of secondary outcomes showed only weak statistical evidence. CONCLUSIONS: In this randomized controlled trial, FE-DALK and S-DALK showed comparable functional and anatomical outcomes.
Subject(s)
Astigmatism , Corneal Transplantation , Keratoconus , Humans , Visual Acuity , Astigmatism/surgery , Treatment Outcome , Keratoplasty, Penetrating , Keratoconus/surgery , Retrospective Studies , Follow-Up StudiesABSTRACT
OBJECTIVE: To compare subjective and objective outcomes of 4 different Descemet membrane endothelial keratoplasty (DMEK) peeling techniques performed by novice surgeons at different stages in their surgical career. DESIGN: An ex vivo prospective study. METHODS: In the first round, 2 DMEK peeling techniques were pitched against each other: the peripheral scoring and Sinskey dissection technique with the peripheral scoring and microhoe dissection and the peripheral blunt microhoe dissection against the scleral spurectomy and microhoe dissection. Three surgeons with different operative experience performed the peeling. Outcome measures included graft peeling time, surgeon's peeling difficulty grading (on a scale of 1-10, 1 being the easiest and 10 the hardest), number of radial and circumferential tears before and after trephination, and tissue loss. The 2 techniques that performed the best from the first round proceeded to the final round to identify the best overall technique. RESULTS: In total, 90 tissues (45 pairs) were peeled by 3 surgeons. Following the first-round results, the peripheral scoring and Sinskey dissection and peripheral blunt microhoe dissection proceeded to the final round. There were no significant differences between the groups in terms of peeling times, subjective feeling of difficulty, post-trephination tears, and peeling success rates (P > 0.05 for all). However, the peripheral scoring and Sinskey dissection technique had significantly fewer pretrephination radial tears (1.3 ± 1.3 vs 6.1 ± 5.2, Pâ¯=â¯0.007) and circumferential tears (0.6 ± 0.9 vs 1.8 ± 2.1, Pâ¯=â¯0.02). CONCLUSIONS: This study demonstrates that the learning curve can be overcome quickly with appropriate DMEK peeling techniques. The peripheral scoring and Sinskey dissection peeling technique allows efficient peeling with fewer related tears.
Subject(s)
Descemet Membrane , Descemet Stripping Endothelial Keratoplasty , Humans , Descemet Stripping Endothelial Keratoplasty/methods , Prospective Studies , Eye Banks/methods , Tissue and Organ Harvesting , Endothelium, Corneal , Retrospective StudiesABSTRACT
PURPOSE: The purpose of this study was to assess long-term stability and outcomes of femtosecond astigmatic keratotomy (FSAK) after treatment of high postkeratoplasty astigmatism. METHODS: This retrospective study included patients who underwent FSAK for high astigmatism (≥4 D) after penetrating keratoplasty or deep anterior lamellar keratoplasty. Main outcome measures were corneal astigmatism, uncorrected visual acuity, and best-corrected visual acuity (BCVA) at 1 month and 1, 5, and 10 years. RESULTS: Overall, 61 eyes of 61 patients (mean age 56 ± 19 years, 54.1% male) were included in this study. Preoperative corneal astigmatism ranged from 4 to 25 D. One month after FSAK, mean corneal astigmatism was significantly reduced from 9.02 ± 3.97 D to 4.86 ± 3.10 D ( P < 0.001). Thereafter, corneal astigmatism remained stable at all visits up to 10 years ( P < 0.05 for all compared with baseline). After FSAK, there was a significant improvement in logMAR uncorrected visual acuity from 1.21 ± 0.48 to 0.87 ±0.54 ( P < 0.001) and logMAR BCVA from 1.03 ± 0.55 to 0.49 ± 0.45 ( P < 0.001) which remained stable up to 10 years. A mild reduction in BCVA improvement was seen between 1 month and 1 year. CONCLUSIONS: Femtosecond astigmatic keratotomy was effective and stable at reducing very high magnitudes of postkeratoplasty astigmatism over the long term. The procedure also had a stable effect on visual acuity, albeit some reduction in the degree of BCVA improvement was seen over the early postoperative period.
Subject(s)
Astigmatism , Corneal Diseases , Humans , Male , Adult , Middle Aged , Aged , Female , Keratoplasty, Penetrating/adverse effects , Refraction, Ocular , Astigmatism/etiology , Astigmatism/surgery , Retrospective Studies , Corneal Topography , Cornea/surgery , Corneal Diseases/surgery , Postoperative Complications/surgeryABSTRACT
OBJECTIVE: To review the distribution, current trends, and resistance patterns of bacterial keratitis isolates in Toronto over the last 11 years. DESIGN: Retrospective, observational, case series. PARTICIPANTS: Microbiology records of suspected bacterial keratitis cases that underwent a diagnostic corneal scraping and cultures from January 1, 2000, through December 31, 2010, were reviewed. METHODS: Culture results and antibiotic sensitivity profiles were reviewed and analyzed. MAIN OUTCOME MEASURES: Distribution of the main isolated pathogens as well as in vitro laboratory minimum inhibitory concentration testing results to identify resistance patterns. RESULTS: A total of 1701 consecutive corneal scrapings were taken during the 11 years of the study. A pathogen was recovered in 977 samples (57.4%), with bacterial keratitis accounting for 897 of the positive cultures (91.8%). The total number of Gram-positive and Gram-negative isolates was 684 and 213, respectively. We identified a decreasing trend in Gram-positive isolates (P = 0.016). The most common isolate overall was coagulase-negative Staphylococcus (CNS) and the most common Gram-negative bacteria isolated was Pseudomonas aeruginosa. Methicillin-resistant Staphylococcus aureus (MRSA) was present in 1.3% of the S aureus isolates, whereas methicillin-resistant CNS (MRCNS) was present in 43.1% of the CNS isolates. There was a trend toward increasing laboratory resistance to methicillin from 28% during the first 4 years of the study to 38.8% for the last 3 years (P = 0.133). When analyzing the sensitivities of MRSA and MRCNS isolates to other antibiotics, there was resistance to cefazolin and sensitivity to vancomycin in all isolates, whereas resistance to other antibiotics was variable. CONCLUSIONS: There was a significant decrease in the percentage of Gram-positive microorganisms over time. The sensitivity of Gram-negative isolates to tested antimicrobials was >97% response for all the reported antibiotics; this was not the case for Gram-positive isolates, in which resistance to the antibiotics was more common. Methicillin-resistant organisms accounted for 29.1% of all Gram-positive cultures in our series, suggesting that the empiric use of vancomycin in the setting of severe suspected bacterial keratitis may be justified.
Subject(s)
Corneal Ulcer/microbiology , Eye Infections, Bacterial/microbiology , Gram-Negative Bacterial Infections/microbiology , Gram-Positive Bacterial Infections/microbiology , Adult , Anti-Bacterial Agents/pharmacology , Anti-Bacterial Agents/therapeutic use , Cornea/microbiology , Corneal Ulcer/epidemiology , Drug Resistance, Bacterial , Eye Infections, Bacterial/epidemiology , Female , Gram-Negative Bacteria/drug effects , Gram-Negative Bacteria/isolation & purification , Gram-Negative Bacterial Infections/epidemiology , Gram-Positive Bacteria/drug effects , Gram-Positive Bacteria/isolation & purification , Gram-Positive Bacterial Infections/epidemiology , Humans , Male , Microbial Sensitivity Tests , Ontario/epidemiology , Retrospective StudiesABSTRACT
OBJECTIVE: To determine which measure of the salivary flow rate, stimulated or unstimulated, is most strongly associated with pathologic changes in minor salivary gland (MSG) biopsy specimens, and to explore the correlation of salivary flow with oral surface damage, disease duration, and symptom severity in patients with primary Sjögren's syndrome (SS). METHODS: In all patients (n = 32), a biopsy of the MSG was performed, and stimulated salivary flow was assessed. Beginning in 2002, unstimulated salivary flow was also assessed. Scores for the severity of symptoms, according to the decayed/missing/filled teeth (DMF) index, were recorded. Associations between measures of salivary flow and covariates characterizing pathology were examined. RESULTS: A definite association between stimulated salivary flow and the MSG focus score, the grade of MSG fibrosis, the duration of dry mouth symptoms, and the DMF score was observed. In contrast, unstimulated salivary flow was not associated with fibrosis, atrophy, the DMF score, or the duration of dry mouth symptoms. In patients with primary SS, the DMF score was associated with pathologic changes in the MSG. Among patients with sicca, 57.9% had an abnormal unstimulated salivary flow rate (versus 82.4% of patients with primary SS), and 15.2% had an abnormal stimulated salivary flow rate (versus 61.8% of patients with primary SS). Among patients with sicca, neither stimulated salivary flow nor unstimulated salivary flow was associated with the degree of fibrosis or atrophy or with the DMF score. CONCLUSION: Compared with unstimulated salivary flow, stimulated salivary flow appeared to be a better measure of inflammation (according to the focus score) and fibrosis. In patients with sicca, the unstimulated salivary flow rate appeared to be abnormal more commonly compared with the stimulated salivary flow rate. In the future, stimulated salivary flow may serve as a noninvasive surrogate biomarker of inflammation and fibrosis as well as a measure of response to treatment in patients with primary SS.
Subject(s)
Inflammation/pathology , Salivary Glands/pathology , Salivation/physiology , Sjogren's Syndrome/pathology , Adult , Aged , Female , Humans , Inflammation/physiopathology , Linear Models , Male , Middle Aged , Salivary Glands/physiopathology , Sjogren's Syndrome/complications , Sjogren's Syndrome/physiopathology , Xerostomia/complications , Xerostomia/pathology , Xerostomia/physiopathologyABSTRACT
To evaluate the use of combined topical and intracameral anesthesia for Descemet's stripping automated keratoplasty (DSAEK). This was a retrospective comparative cohort analysis consisting of 10 eyes in 10 consecutive patients undergoing DSAEK surgery with combined topical and intracameral anesthesia. These cases were compared with 21 randomly selected controls during the same time period undergoing DSAEK surgery performed under retrobulbar anesthesia. Incidence of intraoperative and postoperative complications, and endothelial cell counts were compared. In all cases, DSAEK was completed without intraoperative complications. All patients tolerated the procedure well. There were 6 cases of postoperative graft dislocation requiring rebubbling, and no cases of primary failure or endophthalmitis. No significant difference in endothelial cell counts was found at final follow-up. Short-term results suggest that combined topical and intracameral anesthesia is as safe and effective for DSAEK in cooperative patients when compared to retrobulbar anesthesia. It may thereby be an alternative anesthetic modality for patients in whom retrobulbar or peribulbar anesthesia may be risky or contraindicated.
Subject(s)
Anesthesia, Local/methods , Anesthetics, Combined/administration & dosage , Anesthetics, Local/administration & dosage , Anterior Chamber/drug effects , Descemet Stripping Endothelial Keratoplasty , Aged , Aged, 80 and over , Anesthetics, Combined/adverse effects , Anesthetics, Local/adverse effects , Cell Count , Cohort Studies , Endothelium, Corneal , Female , Humans , Lidocaine/administration & dosage , Lidocaine/adverse effects , Male , Middle Aged , Propoxycaine/administration & dosage , Propoxycaine/adverse effects , Retrospective Studies , Treatment Outcome , Visual Acuity/physiologyABSTRACT
PURPOSE: The purpose of this study was to report a case of "smoldering" keratolimbal allograft (KLAL) rejection in a patient with subtherapeutic levels of systemic immunosuppression in temporal association with BNT162b2 messenger RNA vaccination for severe acute respiratory syndrome coronavirus 2. METHODS: This was a case report. OBSERVATIONS: A 72-year-old man presented with circumferential perilimbal engorgement, stagnation, and tortuosity of vessels with mild chemosis in his right eye KLAL segments 1 month after receiving the BNT162b2 messenger RNA vaccine while his tacrolimus trough blood levels were subtherapeutic measuring <2 ng/mL. He had undergone KLAL 6.5 years before for total limbal stem cell deficiency from a chemical injury and had been stable without any history of rejection. The donor was blood type O, and the patient had no systemic comorbidities. The patient was treated with hourly difluprednate 0.05% and increasing of his oral tacrolimus dose to 2 mg twice a day with improvement of rejection signs. CONCLUSIONS: There may be a temporal association between KLAL rejection after immunization against severe acute respiratory syndrome coronavirus 2 in patients with subtherapeutic levels of systemic immunosuppression. Patients should be on alert for any ocular signs or symptoms postimmunization and present for treatment immediately.
Subject(s)
COVID-19 , Corneal Diseases , Limbus Corneae , Aged , Allografts , BNT162 Vaccine , Corneal Diseases/diagnosis , Corneal Diseases/etiology , Graft Rejection/etiology , Humans , Male , Stem Cell Transplantation/adverse effects , Vaccines, Synthetic , mRNA VaccinesABSTRACT
PURPOSE: This study aims to determine predictive factors for success of Descemet stripping only (DSO) in Fuchs corneal endothelial dystrophy and propose a DSO treatment algorithm. METHODS: Ovid MEDLINE, Embase, and Cochrane CENTRAL databases were searched to evaluate DSO case series, including combined phacoemulsification and DSO, and the use of Rho-kinase inhibitors (ROC-i). Our primary outcome was success of corneal clearance. Secondary outcomes included the time to corneal clearance, the postoperative endothelial cell count (ECC), and the impact of ROC-i. RESULTS: Sixty-eight cases were evaluated with a mean follow-up of 12.4 months. DSO corneal clearance was achieved in 85% (n = 58) with a mean time of 4.9 weeks for the ROC-i group compared with 10.1 weeks in the observation group (P < 0.0001). The mean central ECC postoperatively was higher in the ROC-i group compared with the observation group 1151 ± 245 versus 765 ± 169 cells/mm2, respectively (P < 0.018). The postoperative best-corrected visual acuity (BCVA) improved in 61 eyes (90%), with mean final BCVA of 0.17 (0.26) logMAR (P = 0.001), which was statistically significant compared with preoperative BCVA. Factors influencing success were 4-mm descemetorhexis size, a clear peripheral ECC with no clinical sequelae of decompensation or guttae, and a low central corneal thickness. No intraoperative complications were noted. The commonest postoperative complication was deep corneal stromal scars noted at the descemetorhexis edge (n = 9). CONCLUSIONS: DSO has a role in the treatment of a subset of patients with Fuchs corneal endothelial dystrophy and that adjuvant treatment with ROC-i may lead to faster corneal clearance.
Subject(s)
Descemet Stripping Endothelial Keratoplasty , Fuchs' Endothelial Dystrophy , Algorithms , Cell Count , Descemet Membrane/surgery , Endothelium, Corneal/surgery , Fuchs' Endothelial Dystrophy/complications , Humans , Visual AcuityABSTRACT
PURPOSE: The scrolling properties of the Descemet membrane endothelial keratoplasty (DMEK) graft are essential for surgical success. Currently, there is limited knowledge on what dictates the tightness of the DMEK scroll. The purpose of this study was to determine the impact of temperature and protein digestion on DMEK graft scroll tightness. METHODS: For the temperature experiment, a total of 28 eyes were used for this study. Scrolls in the cold group were kept at 4°C while scrolls in the hot group were kept at 37°C. Scroll width was recorded at the 5-, 15-, and 30-minute mark. For the protein digestion experiment, a total of 18 eyes were exposed to collagenase A (10 CDU/mL) in Optisol solution. Scroll width was recorded at the time points of 1, 3, 5, 10, and 20 minutes. RESULTS: The results of the temperature experiment did not yield any statistically significant changes in the mean scroll width of the DMEK scrolls across both temperature ranges and observation times. For the protein digestion experiment, the mean scroll width grew from 1.85 mm to 2.13 mm from the beginning of the experiment until the final observation at 20 minutes. This is a 14.7% change over 20 minutes with a P value (<0.001), exemplifying a statistically significant change in scroll width. CONCLUSIONS: Temperature did not have any significant effect over scroll tightness, but scroll tightness decreased with collagenase exposure.