Corneal endothelial cell loss and intraocular pressure following phacoemulsification using a new viscous-cohesive ophthalmic viscosurgical device.

PURPOSE: To compare results of two ophthalmic viscosurgical devices (OVDs)-Viscoat (a dispersive OVD, Alcon) and FR-Pro (a viscous-cohesive OVD, Rayner), in phacoemulsification surgery. METHODS: A prospective randomized controlled study. Patients undergoing phacoemulsification were randomly assigned to receive one of the two OVDs. Exclusion criteria were age under 40, preoperative endothelial cell count (ECC) below 1,500 cells/mm2 and an eventful surgery. The primary outcome was change in ECC from baseline to postoperative month one and month three. Secondary outcomes were the difference between ECC at postoperative month one and month three, changes in IOP and occurrence of an IOP spike ≥ 30 mmHg after surgery. RESULTS: The study included 84 eyes-43 in the Viscoat group and 41 in the FR-Pro group. Mean cell density loss at month one and month three was 17.0 and 19.2%, respectively, for the Viscoat group and 18.4 and 18.8%, respectively, for the FR-Pro group, with no statistically significant difference between the groups (p = 0.772 and p = 0.671, respectively). The mean ECC difference between the month one and month three visits was 50.5 cells/mm2 and was not statistically significant (p = 0.285). One eye in each group had an IOP spike ≥ 30 mmHg, both normalized by postoperative week one. CONCLUSIONS: Viscoat and FR-Pro have comparable results following phacoemulsification surgery, suggesting that while FR-Pro is not a dispersive OVD, its endothelial cell protection may be comparable to one, perhaps due to the addition of sorbitol. Furthermore, a one-month follow-up of ECC seems sufficient in such trials.

Determination of progressive endothelial cell loss after posterior chamber phakic intraocular lens implantation.

Comments about endothelial cell loss after posterior chamber phakic intraocular lens are provided, with a particular emphasis on the importance of determining progressive postoperative cell density reduction, excluding that related to surgical trauma.

Corneal endothelial cell loss after EX-PRESS surgery depends on site of insertion, cornea or trabecular meshwork.

PURPOSE: Previously, we reported that the Ex-press® shunt (EXP) was associated with more rapid reduction in corneal endothelial cells when inserted into the cornea rather than the trabecular meshwork (TM). We compared the reduction rate of corneal endothelial cells between the corneal insertion group and TM insertion group. METHODS: This was a retrospective study. We included patients who had undergone EXP surgery and were followed for > 5 years. We analyzed the corneal endothelial cell density (ECD) before and after EXP implantation. RESULTS: We included 25 patients in the corneal insertion group and 53 patients in the TM insertion group. One patient in the corneal insertion group developed bullous keratopathy. The ECD decreased significantly more rapidly in the corneal insertion group (p < 0.0001), in whom the mean ECD decreased from 2227 ± 443 to 1415 ± 573 cells/mm2 at 5 years with a mean 5-year survival rate of 64.9 ± 21.9%. By contrast, in the TM insertion group, the mean ECD decreased from 2356 ± 364 to 2124 ± 579 cells/mm2 at 5 years, and the mean 5-year survival rate was 89.3 ± 18.0%. The decrease rate of ECD was calculated as 8.3%/year in the corneal insertion group and 2.2%/year in the TM insertion group. CONCLUSIONS: Insertion into cornea is a risk factor for rapid ECD loss. The EXP should be inserted into the TM to preserve the corneal endothelial cells.

Corneal Endothelial Cell Density Loss after Glaucoma Surgery Alone or in Combination with Cataract Surgery: A Systematic Review and Meta-analysis.

TOPIC: Corneal endothelial cell density (ECD) loss after glaucoma surgery with or without cataract surgery. CLINICAL RELEVANCE: Corneal ECD loss may occur as the result of intraoperative surgical trauma in glaucoma surgery or postoperatively with chronic endothelial cell trauma or irritation. METHODS: Glaucoma filtration surgery or microinvasive glaucoma surgery (MIGS) in participants with ocular hypertension, primary and secondary open-angle glaucoma, normal-tension glaucoma, and angle-closure glaucoma were included. Electronic databases searched in December 2021 included MEDLINE, Embase, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, the International Prospective Register of Systematic Reviews, Food and Drug Administration (FDA) Premarket Approval, and FDA 510(k). RESULTS: A total of 39 studies were included in quantitative synthesis. Twelve months after suprachoroidal MIGS, mean ECD loss was 282 cells/mm2 (95% confidence interval [CI], 220-345; P < 0.00001; chi-square = 0.06; I2 = 0%; 2 studies; very low certainty). Mean ECD loss after Schlemm's canal implantable devices was 338 cells/mm2 (95% CI, 185-491; P < 0.0001; chi-square = 0.08; I2 = 0%; 2 studies; low certainty) at 12 months. Mean ECD loss was 64 cells/mm2 (95% CI, 21-107; P = 0.004; chi-square = 4.55; I2 = 0%; 6 studies; low certainty) after Schlemm's canal procedures (without implantable devices) at 12 months. At 12 months, the mean ECD loss after trabeculectomy was 33 cells/mm2 (95% CI, -38 to 105, P = 0.36, chi-square = 1.17; I2 = 0%; moderate certainty). At 12 months, mean ECD loss was 121 cells/mm2 (95% CI, 53-189; P = 0.0005; chi-square = 3.00; I2 = 0%; 5 studies; low certainty) after Express (Alcon) implantation. When compared with the control fellow eye, aqueous shunt surgery reduced ECD by 5.75% (95% CI, -0.93 to 12.43; P = 0.09, chi-square = 1.32; I2 = 0%; low certainty) and 8.11% ECD loss (95% CI, 0.06-16.16 P = 0.05; chi-square = 1.93; I2 = 48%) at 12 and 24 months, respectively. CONCLUSIONS: Overall, there is low certainty evidence to suggest that glaucoma surgery involving long-term implants has a greater extent of ECD loss than glaucoma filtration surgeries without the use of implants. The results of this review support follow-up beyond 36 months to assess ECD loss and corneal decompensation after implantation of glaucoma drainage implants.

Graft survival of Descemet membrane endothelial keratoplasty (DMEK) in corneal endothelial decompensation after glaucoma surgery.

PURPOSE: This study aims to assess the results, rebubbling rate, and graft survival after Descemet membrane endothelial keratoplasty (DMEK) with regard to the number and type of previous glaucoma surgeries. METHODS: This is a clinical retrospective review of 1845 consecutive DMEK surgeries between 07/2011 and 08/2017 at the Department of Ophthalmology, University of Cologne. Sixty-six eyes were included: group 1 (eyes with previous glaucoma drainage devices (GDD); n = 27) and group 2 (eyes with previous trabeculectomy (TE); n = 39). Endothelial cell loss (ECL), central corneal thickness, graft failure, rebubbling rate, and best spectacle-corrected visual acuity (BSCVA) up to 3 years after DMEK were compared between subgroups of patients with different numbers of and the two most common types of glaucoma surgeries either GDD or TE or both. RESULTS: Re-DMEK rate due to secondary graft failure was 55.6% (15/27) in group 1 and 35.9% in group 2. The mean graft survival time in group 1 was 25 ± 11 months and 31.3 ± 8.6 months in group 2 (p = 0.009). ECL in surviving grafts in group 1 was 35% (n = 13) at 6 months, 36% at 12 months (n = 8), and 27% (n = 4) at 2 years postoperatively. In group 2, ECL in surviving grafts was 41% (n = 10) at 6 months, 36% (n = 9) at 12 months, and 38% (n = 8) at 2 years postoperatively. Rebubbling rate in group 1 was 18.5% (5/27) and 35.9% (14/39) in group 2 (p = 0.079). CONCLUSION: Eyes with previous GDD had no higher risk for an increased rebubbling rate but a higher risk for a re-DMEK due to secondary graft failure with a mean transplant survival time of about 2 years. Compared to eyes with preexisting glaucoma drainage device, eyes after trabeculectomy had less secondary graft failures and a longer mean graft survival rate.

The Effect of Tube Location on Corneal Endothelial Cells in Patients with Ahmed Glaucoma Valve.

PURPOSE: To compare the effects of the Ahmed glaucoma valve (AGV; New World Medical, Rancho Cucamonga, CA) with sulcus versus anterior chamber (AC) tube placement on the corneal endothelial density and morphology over time. DESIGN: Nonrandomized, interventional study. PARTICIPANTS: This study included 106 eyes from 101 pseudophakic patients who had the AGV tube placed in the AC (acAGV) and 105 eyes from 94 pseudophakic patients who had the AGV tube placed in the ciliary sulcus (sAGV). METHODS: All patients underwent preoperative specular microscopy, which was repeated postoperatively in 2019. The patients' demographic information, glaucoma diagnoses, and basic ocular information were obtained on chart review. Anterior segment OCT was conducted for patients who underwent sAGV to evaluate the sulcus tube position. Gonioscopy was performed to document peripheral anterior synechiae (PAS). Linear mixed-effects models were used to compare the different ocular and endothelial measurements between the 2 groups and to identify risk factors for endothelial cell density (ECD) loss over time. MAIN OUTCOME MEASURES: Monthly change in corneal endothelial measurements, including ECD and coefficient of variation (CV), calculated as the difference between preoperative and postoperative measurements divided by the number of months from the time of surgery to postoperative specular microscopy. RESULTS: The acAGV and sAGV groups were comparable in all baseline characteristics except that the acAGV group had longer follow-up (37.6 vs. 20.1 months, respectively, P < 0.001). Mean monthly loss in central ECD was significantly more in the acAGV group (mean ± standard deviation: 29.3±29.7 cells/mm2) than in the sAGV group (15.3±20.7 cells/mm2, P < 0.0001). Mean monthly change in CV was similar between the 2 groups (P = 0.28). Multivariate analyses revealed that younger age and tube location in the AC were associated with faster central ECD loss (P = 0.02, P < 0.0001, respectively). For patients with sAGV, while PAS was associated with faster central ECD loss (P = 0.002), a more forward tube position tenting the iris was not (P > 0.05). CONCLUSIONS: Compared with anterior segment placement, ciliary sulcus tube implantation may be a preferred surgery approach to reduce endothelial cell loss in pseudophakic patients.

Ab interno supraciliary microstent surgery for open-angle glaucoma.

BACKGROUND: Glaucoma is the leading cause of global irreversible blindness, often associated with raised intraocular pressure (IOP). Where medical or laser treatment has failed or is not tolerated, surgery is often required. Minimally-invasive surgical approaches have been developed in recent years to reduce IOP with lower surgical risks. Supraciliary microstent surgery for the treatment of open-angle glaucoma (OAG) is one such approach. OBJECTIVES: To evaluate the efficacy and safety of supraciliary microstent surgery for the treatment of OAG, and to compare with standard medical, laser or surgical treatments. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL; which contains the Cochrane Eyes and Vision Trials Register; 2020, Issue 8); Ovid MEDLINE; Ovid Embase; the ISRCTN registry; ClinicalTrials.gov and the WHO ICTRP. The date of the search was 27 August 2020. SELECTION CRITERIA: We searched for randomised controlled trials (RCTs) of supraciliary microstent surgery, alone or with cataract surgery, compared to other surgical treatments (cataract surgery alone, other minimally invasive glaucoma device techniques, trabeculectomy), laser treatment or medical treatment. DATA COLLECTION AND ANALYSIS: Two review authors independently screened titles and abstracts from the database search to identify studies that met the selection criteria. Data extraction, analysis, and evaluation of risk of bias from selected studies was performed independently and according to standard Cochrane methodology. MAIN RESULTS: One study met the inclusion criteria of this review, evaluating the efficacy and safety of the Cypass supraciliary microstent surgery for the treatment of OAG, comparing phacoemulsification + supraciliary microstent surgery with phacoemulsification alone over 24 months. This study comprised 505 eyes of 505 participants with both OAG and cataract, 374 randomised to the phacoemulsification + microstent group.  In this study, the perceived risk of bias from random sequence generation, allocation concealment and selective reporting was low. However, we considered the study to be at high risk of performance bias as surgeons/investigators were unmasked. Attrition bias was unclear, with 448/505 participants contributing to per protocol analysis. Insertion of a Cypass supraciliary microstent combined with phacoemulsification probably increases the proportion of participants who are medication-free (not using eye-drops) at 24 months compared with phacoemulsification alone (85% versus 59%, risk ratio (RR) 1.27, 95% confidence interval (CI) 1.09 to 1.49, moderate-certainty evidence). There is high-certainty evidence that a greater improvement in mean IOP occurs in the phacoemulsification + microstent group - mean (SD) change in IOP from baseline of -5.4 (3.9) mmHg in the phacoemulsification group, compared to -7.4 (4.4) mmHg in the phacoemulsification + microstent group at 24 months (mean difference -2.0 mmHg, 95% CI -2.85 to -1.15). There is moderate-certainty evidence that insertion of a microstent is probably associated with a greater reduction in use of IOP-lowering drops (mean reduction of 0.7 medications in the phacoemulsification group, compared to a mean reduction of 1.2 medications in the phacoemulsification + microstent group). Insertion of a microstent during phacoemulsification may reduce the requirement for further glaucoma intervention to control IOP at a later stage compared to phacoemulsification alone (RR 0.26, 95% CI 0.07 to 1.04, low-certainty evidence). There is no evidence relating to the rate of visual field progression, or proportion of participants whose visual field loss progressed in this study. There is moderate-certainty evidence showing little or no difference in the proportion of participants experiencing postoperative complications over 24 months between participants in the microstent group compared to those who received phacoemulsification alone (RR 1.1, 95% CI 0.8 to 1.4). Five year post-approval data regarding the safety of the Cypass supraciliary microstent showed increased endothelial cell loss, associated with the position of the microstent in the anterior chamber. There were no reported health-related quality of life (HRQoL) outcomes in the included study. AUTHORS' CONCLUSIONS: Data from this single RCT show superiority of supraciliary microstent surgery when combined with phacoemulsification compared to phacoemulsification alone in achieving medication-free control of OAG. However, there are long-term safety concerns with the device used in this trial, relating to the observed significant loss of corneal endothelial cells at five years following device implantation. At the time of this review, this device has been withdrawn from the market. This review has found that few high-quality studies exist comparing supraciliary microstent surgery to standard medical, laser or surgical glaucoma treatments. This should be addressed by further appropriately designed RCTs with sufficient long-term follow-up to ensure robust safety data are obtained. Consideration of health-related quality of life outcomes should also feature in trial design.

Accelerated corneal endothelial cell loss in two patients with granulomatosis with polyangiitis following phacoemulsification.

BACKGROUND: Generally, the loss rate of human endothelial cells (HCEC) in routine cataract surgery is 8.5%. When the corneal endothelial cells density (ECD) drops, the HCEC may decompensate to keep cornea dehydration which leads to corneal edema. Granulomatosis with polyangiitis (GPA) is an uncommon autoimmune disease involving multiple organs including eyes such as conjunctivitis, scleritis, uveitis, and corneal ulcer. In this study, we report two cases of GPA whose corneal ECD decreased significantly after phacoemulsification cataract surgery. CASE PRESENTATION: In the first case of 69-year-old male with GPA, the ECD dropped 39.6% (OD) four months after phacoemulsification and 38.1% (OS) six months postoperatively respectively. At the final follow-up, the residual ECD was only 55% in the right eye in the 49th month, and 56% remained in the left eye in the 39th month. In the second case of 54-year old female, left ECD dropped 63.9% at the 4th month after surgery and 69.6% ECD remained at the 15th month postoperatively while similar ECD of right eye before and after left eye surgery. CONCLUSION: Extensive preoperative ophthalmic evaluation and meticulous postoperative inflammation control should be applied to prevent severe loss of HCEC in GPA patients.

A prospective comparative study on endothelial cell loss and morphology after femtolaser-assisted cataract surgery and phacoemulsification.

PURPOSE: To compare changes in endothelial cell count and morphology at 6 months follow-up in eyes undergoing femtosecond laser-assisted cataract surgery (FLACS) and conventional phacoemulsification. DESIGN: Prospective, comparative and open-label study. METHODS: All consenting patients between 50 and 75 years of age with uncomplicated cataract underwent either FLACS [Catalys Precision Laser System (OptiMedica Corp.; Abbott Medical Optics)] or conventional phacoemulsification [Bausch + Lomb Stellaris® (Rochester, USA)] based on their preference and were followed up on day 15 and at 2 and 6 months postoperatively. The endothelial cell count (ECC), % of hexagonal cells and coefficient of variation were noted at baseline and at each follow-up visit and compared between groups. RESULTS: A total of 187 eyes of 187 patients (n = 98 in phaco vs. n = 89 in FLACS) were enrolled. At 15 days follow-up, there was a significant decline in the endothelial cell count in both groups (187 ± 156 in phaco vs. 193 ± 240 in FLACS, p < 0.001). In subsequent visits, the ECC remained stable (8% decline in phaco vs. 7.7% decline in femto, p = 0.87) till last follow-up at 6 months. The %hexagonal cells also decreased significantly at 15 days post-op (p < 0.001) but did not show any change in subsequent visits. The coefficient of variation in ECC did not change significantly throughout the study period. Eyes with higher endothelial cell count at baseline tended to lose more cells (b = 25.7 cells/mm3, 95% CI 16-35 cells, p = 0.01) irrespective of age and type of surgery. CONCLUSIONS: Both procedures are equally safe with < 10% ECC loss at 6 months. Longer studies are required to determine influence of FLACS on ECC.

Factors influencing the reduction in corneal endothelial cells after Ex-Press® surgery.

PURPOSE: We investigated the factors that influence the reduction in corneal endothelial cells after Ex-Press® surgery. METHODS: This was a retrospective study. We included patients who had undergone Ex-Press surgery and were followed up for > 2. We analyzed the corneal endothelial cell density (ECD) before and after Ex-Press surgery. We investigated the insertion position (Ex-Press device was inserted into cornea or trabecular meshwork (TM)), Ex-Press-iris touch, cornea-iris touch, peripheral anterior synechiae, history of trabeculotomy, history of selective laser trabeculoplasty, type of glaucoma, and simultaneous cataract surgery as influencing factors. We used multivariate analysis to determine the factors influencing the reduction rate of ECD. RESULTS: We included 129 eyes. The mean of ECD had decreased 7.0% at 2 years. Ex-Press surgeries significantly decreased the ECD after 2 years (p = 0.0118). As a result of the multivariate analysis, the factor that led to a significantly faster reduction in ECD was the insertion position of the Ex-Press (p < 0.0001). The reduction rate of ECD after 2 years in cases of insertion into the cornea (27 eyes) was 15.1 ± 3.6%, and in cases of insertion into a TM (102 eyes), it was 5.2 ± 1.4%. CONCLUSIONS: Insertion into the cornea was a risk factor for rapid ECD loss. The Ex-Press should be inserted into a TM for long-term protection of the corneal endothelial cells.

Postoperative Endothelial Cell Density Is Associated with Late Endothelial Graft Failure after Descemet Stripping Automated Endothelial Keratoplasty.

PURPOSE: To determine whether preoperative endothelial cell density (ECD) and postoperative ECD after Descemet stripping automated endothelial keratoplasty (DSAEK) are associated with late endothelial graft failure (LEGF) in the Cornea Preservation Time Study (CPTS). DESIGN: Cohort study within a multicenter, randomized clinical trial. PARTICIPANTS: A total of 1007 individuals (1223 study eyes), mean age 70 years, undergoing DSAEK for Fuchs' dystrophy (94% of eyes) or pseudophakic or aphakic corneal edema (PACE) (6% of eyes) and followed for up to 5 years. METHODS: Central ECD was determined by a central image analysis reading center. Preoperative ECD was determined for 1209 eyes that did not fail and 14 eyes that experienced LEGF. The ECD at 6 and 12 months after DSAEK, the change in ECD from preoperative to 6 and 12 months, surgeon-reported operative complications, and postoperative graft dislocation were investigated for an association with LEGFs unrelated to other postoperative events. Univariable and multivariable Cox proportional hazards regression models were used to assess associations. MAIN OUTCOME MEASURES: Late endothelial graft failure and its associations with pre- and postoperative ECD and operative complications. RESULTS: The cumulative probability of LEGF was 1.3% (95% confidence interval [CI], 0.8%-2.4%). Median (interquartile range [IQR]) preoperative ECDs were similar for eyes with LEGF (2523; 2367-3161) cells/mm2) and eyes without failure (2727; 2508-2973) cells/mm2) (P = 0.34). The ECD at 6 months was associated with LEGF (P < 0.001) in time-to-event analyses, whereas preoperative ECD was not (P = 0.55). The cumulative incidence (95% CI) of LEGF was 6.5% (3.0%, 14.0%) for 97 grafts with a 6-month ECD less than 1200 cells/mm2, 0.3% (0.0%, 2.4%) for 310 grafts with a 6-month ECD between 1200 and 2000 cells/mm2, and 0.6% (0.1%, 2.7%) for 589 grafts with a 6-month ECD greater than 2000 cells/mm2. In multivariable analyses, ECD at 6 months and operative complications were both associated with LEGF (P = 0.002 and P = 0.01, respectively), whereas graft dislocation was not (P = 0.61). CONCLUSIONS: In eyes undergoing DSAEK, preoperative ECD is unrelated to LEGF, whereas lower ECD at 6 months is associated with LEGF. Early endothelial cell loss after DSAEK and intraoperative complications should be minimized to improve graft survival.

Long-term endothelial cell loss with the iris-claw intraocular phakic lenses (Artisan®).

PURPOSE: To evaluate the endothelial cell loss in patients with iris-claw phakic lenses (Artisan®) in a long-term follow-up. METHODS: We analyzed the medical records of patients who had undergone iris-claw phakic lens implantation and who had at least 5 years of follow-up. RESULTS: We included 67 eyes with myopic errors (follow-up 9.6 ± 3.0 years) and 10 eyes with mixed astigmatism or hyperopic errors (follow-up 8.8 ± 2.5 years). The mean total endothelial density loss at the last follow-up visit was 18.5% ± 17.0% and 10.5% ± 12.3%, respectively. 29.9% of the eyes in the myopic group and 20% in the hyperopic group lost more than 25% of the preoperative endothelial cell density. During the postoperative follow-up period, 60.8% of the eyes in the myopic group and 40% of the eyes in the hyperopic group lost a higher percentage than the expected physiological loss. Two eyes in the myopic group (3.0%) had a final cell density of less than 1200 cells/mm2. None of the variables studied had a statistically significant association with the percentage of annual endothelial loss in the postoperative period. Three phakic lenses were explanted: two by cataract and one by cataract and severe decrease of the endothelial density (862 cells/mm2). CONCLUSIONS: There is a significant endothelial cell loss in a low percentage of the eyes with Artisan® lenses in the long term, and it can decrease to critical levels. Periodic endothelial density evaluations are required for these patients. The selection criteria of surgical candidates could be reevaluated.

Changes in corneal endothelial density following scleral buckling surgery for rhegmatogenous retinal detachment: a retrospective cross-sectional study.

BACKGROUND: To investigate the effect of scleral buckling (SB) on the morphology and density of human corneal endothelial cells (HCEC). METHODS: In this retrospective cross-sectional study, 26 patients who had undergone SB due to rhegmatogenous retinal detachment were enrolled, in which 15 patients received encircling while the other 11 segment types of SB. The postoperative status of affected eye, preoperative status of affected eye, and the contralateral healthy eye was served as the study, control and contralateral groups. The images of the corneal endothelium was obtained by specular microscopy at least three months postoperatively and analyzed. RESULTS: Postoperative best-corrected visual acuity of the study group was worse than that of another two groups (P < 0.001) while intraocular pressure and biometry data were similar. The mean cell area and standard deviation were larger in the study group while the coefficient of variation revealed no difference. The study group manifested a lower endothelial cell density than that of the control and the contralateral (P < 0.001) groups. Concerning the percentage of hexagonal cells, the study group showed a lower hexagonality than the control group (P = 0.04). No difference of the endothelial morphology was found between the segmental subgroup and the encircling subgroup, nor was a significant difference about endothelial cell loss found in the study group with different measurement interval. CONCLUSIONS: Scleral buckling leads to short-term decreased endothelial cell density and hexagonality, while the rest of morphological features remain unchanged. Moreover, both the segmental and encircling SB procedures yield similar postoperative HCEC status.

Long-Term Endothelial Cell Loss in Patients with Artisan Myopia and Artisan Toric Phakic Intraocular Lenses: 5- and 10-Year Results.

PURPOSE: To evaluate the long-term change in endothelial cell density (ECD) after the implantation of 2 types of rigid iris-fixated phakic intraocular lenses (pIOLs) for the treatment of myopia and astigmatism. DESIGN: Prospective, clinical cohort study. PARTICIPANTS: A total of 507 eyes of 289 patients receiving the Artisan Myopia or Artisan Toric (Ophtec B.V., Groningen, The Netherlands) iris-fixated pIOL for the treatment of myopia or astigmatism at the University Eye Clinic Maastricht as of January 1998. METHODS: A total of 381 myopic and 126 toric pIOLs were implanted. Five- and 10-year follow-ups were completed by 193 and 127 eyes implanted with the myopic pIOL and by 40 and 20 eyes implanted with the toric pIOL, respectively. MAIN OUTCOME MEASURES: Chronic endothelial cell (EC) loss, percentage of eyes with a decrease of ≥25% in ECD, and percentage of eyes with an ECD <1500 cells/mm2. RESULTS: Chronic EC loss was calculated from 6 months postoperatively to the end of follow-up and showed an annual ECD decline of 48 cells/mm2 (standard error, 3.14) and 61 cells/mm2 (standard error, 6.30) in the myopic (P < 0.001) and toric (P < 0.001) groups, respectively, resulting in a total EC loss of 16.6% and 21.5% from 6 months to 10 years postoperatively, respectively. Ten years after implantation, ECD had decreased by ≥25% in 7.9% and 6.3%, whereas ECD was <1500 cells/mm2 in 3.9% and 4.0% in the myopic and toric groups, respectively. Explantation of the pIOL occurred in 6.0% in the myopic group and 4.8% in the toric group. Risk factors for increased EC loss were a shallow anterior chamber depth (ACD) (P ≤ 0.005) and a smaller distance between the central and peripheral pIOL edge to the endothelium (P ≤ 0.005). CONCLUSIONS: A significant linear chronic EC loss was reported after implantation with myopic or toric iris-fixated pIOLs. A smaller ACD and smaller distance between pIOL edge and endothelium were risk factors for EC loss. Modification of preoperative age-related ECD thresholds is indicated to maintain an ECD that warrants safe future combined pIOL explantation and cataract surgery.

Vulnerability of corneal endothelial cells to mechanical trauma from indentation forces assessed using contact mechanics and fluorescence microscopy.

Corneal endothelial cell (CEC) loss occurs from tissue manipulation during anterior segment surgery and corneal transplantation as well as from contact with synthetic materials like intraocular lenses and tube shunts. While several studies have quantified CEC loss for specific surgical steps, the vulnerability of CECs to isolated, controllable and measurable mechanical forces has not been assessed previously. The purpose of this study was to develop an experimental testing platform where the susceptibility of CECs to controlled mechanical trauma could be measured. The corneal endothelial surfaces of freshly dissected porcine corneas were subjected to a range of indentation forces via a spherical stainless steel bead. A cell viability assay in combination with high-resolution fluorescence microscopy was used to visualize and quantify injured/dead CEC densities before and after mechanical loading. In specimens subjected to an indentation force of 9 mN, the mean ±â€¯SD peak contact pressure P0 was 18.64 ±â€¯3.59 kPa (139.81 ±â€¯26.93 mmHg) in the center of indentation and decreased radially outward. Injured/dead CEC densities were significantly greater (p ≤ 0.001) after mechanical indentation of 9 mN (167 ±â€¯97 cells/mm2) compared to before indentation (39 ±â€¯52 cells/mm2) and compared to the sham group (34 ±â€¯31 cells/mm2). In specimens subjected to "contact only" - defined as an applied indentation force of 0.65 mN - the peak contact pressure P0 was 7.31 ±â€¯1.5 kPa (54.83 ±â€¯11.25 mmHg). In regions where the contact pressures was below 78% of P0 (<5.7 kPa or 42.75 mmHg), injured/dead CEC densities were within the range of CEC loss observed in the sham group, suggesting negligible cell death. These findings indicate that CECs are highly susceptible to mechanical trauma via indentation, supporting the established "no-touch" policy for ophthalmological procedures. While CECs can potentially remain viable below contact pressures of 5.7 kPa (42.75 mmHg), this low threshold suggests that prevention of indentation-associated CEC loss may be challenging.

Descemet stripping automated endothelial keratoplasty versus descemet membrane endothelial keratoplasty: a meta-analysis.

PURPOSE: To evaluate the efficacy and safety of descemet stripping automated endothelial keratoplasty (DSAEK) compared with descemet membrane endothelial keratoplasty (DMEK). METHODS: Databases including PubMed, EMBASE, and Cochrane Library were searched to find studies that compared DSAEK and DMEK outcomes. Efficacy parameters were the postoperative best-corrected visual acuity (BCVA) and spherical equivalent (SE). Safety parameters were postoperative endothelial cell loss (ECL), air injection (rebubbling), graft failure, graft rejection, and high intraocular pressure (IOP). Results from last visit were pooled for the analyses because the follow-up ranged from 3 to 24 months. RESULTS: A total of 7 trials including 433 eyes were selected for this meta-analysis. BCVA was reported in all 7 studies, ECL% and rebubbling rate were reported in 6, and the remaining outcomes were reported in only 3 or 2 studies. Postoperative logMAR BCVA was significantly better for DMEK than that for DSAEK (P < 0.00001). More patients achieved the postoperative BCVA ≥ 20/25 and 20/20 in DMEK group than that in DSAEK (P > 0.001), whereas the proportion of patients whose postoperative BCVA ≥ 20/40 and the amount of SE did not differ statistically (P = 0.32 and P = 0.50, respectively). The DSAEK group has a significantly lower frequency of rebubbling than the DMEK group (P < 0.0001). The postoperative ECL%, graft failure, graft rejection, and high IOP were comparable between the 2 groups (all P values >0.05). CONCLUSIONS: Our meta-analysis suggests that DMEK provided better visual outcomes with similar safety when compared to DSAEK. Given the limited sample size, further investigations are needed to validate these findings.

Corneal endothelial decompensation due to airbag injury.

PURPOSE: We report a case of localized endothelial decompensation due to airbag deployment during a motor vehicle accident. CASE REPORT: A middle-aged woman involved in a motor vehicle accident presented with diminution of vision in left eye. Initial ocular examination revealed corneal abrasion, localized central corneal edema and mild anterior chamber reaction. An anterior-segment ocular coherence tomography (AS-OCT) revealed focal paracentral corneal edema. Patient was managed with lubricating eye drops and antibiotic steroid combination. Significant endothelial cell loss compared to right eye was noted on specular examination. At one- month follow-up, visual acuity recovered to 6/6 but the pleomorphism and polymegathism persisted. CONCLUSION: Airbag-related localized corneal endothelial decompensation is a less known occurrence. This case emphasizes on the fact that serial monitoring of endothelial counts and conservative management can prove beneficial in such scenarios.

Corneal endothelial changes following a single session of selective laser trabeculoplasty for pseudoexfoliative glaucoma.

PURPOSE: To evaluate corneal endothelial cell parameters after a single session of selective laser trabeculoplasty (SLT) in pseudoexfoliative glaucoma (PEG) patients. METHODS: Corneal endothelial cell parameters of 18 PEG patients were compared with 18 healthy subjects following SLT treatment. All patients underwent SLT treatment to 180 degrees of inferior trabecular meshwork. Corneal measurements were performed using specular microscopy (Noncon Robo SP8000, Konan Medical, Hyogo, Japan). Endothelial cell density (ECD), hexagonal cell ratio (HEX), coefficient of variation (CV) of the corneal endothelial cell layer and central corneal thickness of the patients were measured at each visit. RESULTS: There was a statistically significant decrease in ECD (p = 0.004) and a statistically significant increase in CV (p = 0.041) at superior cornea 1 week after SLT. They returned to pre-SLT values at 1 month. One hour post-SLT HEX of inferior cornea was statistically significantly reduced (p = 0.01). At central cornea, there was a significant increase in HEX after 1 week (p = 0.001). Post-SLT IOP showed a significant positive correlation with CV and significant negative correlation with HEX at superior and inferior cornea. There was no correlation between total laser energy used and endothelial cell parameters. CONCLUSION: Effect of a single session of SLT on corneal endothelium of PEG patients appears to be transient, and superior cornea was more affected than central and inferior cornea. All parameters returned to pre-SLT values at 1 month after treatment.

Near infra-red light attenuates corneal endothelial cell dysfunction in situ and in vitro.

In the present study mechanical damage to the corneal endothelium was induced by elevation of intraocular pressure (IOP, 140 mmHg, 60 min) to one eye of rats, delivered either in complete darkness or in the presence of red light (16.5 W/m2, 3000 lx, 625-635 nm). IOP raised in the dark revealed the endothelium to be damaged as staining for the gap junction protein ZO-1 was irregular in appearance with some cells displaced in position or lost to leave gaps or holes. This damage was clearly attenuated when red light was focused through the pupil during the insult of raised IOP. Moreover, staining of endothelium with JC-1 dye showed mitochondria to be activated by both elevated IOP and red light but the activation of mitochondria persisted longer for red light. We interpret this finding to suggest that raised IOP causes apoptosis of endothelial cells and that their mitochondria are activated in the initial stages of the process. In contrast, red light activates mitochondria to induce a protective mechanism to counteract the negative influence of raised IOP on endothelial cells. Evidence is provided to support this notion by the finding that red light stimulates mitochondrial cytochrome oxidase IV (COX IV). Moreover, mitochondria in corneal endothelial cell cultures are activated by red light, revealed by staining with JC-1, that results in an increased rate of proliferation and are also able to counteract toxic insults (sodium azide or cobalt chloride) to the cultures. The present studies therefore show that a non-toxic level of red light attenuates damage to the corneal endothelium both in situ and in vitro through action on COX IV located in mitochondria that results in an enhancement of a cell's survival mechanisms. The study provides proof of principle for the non-invasive use of red-light therapy to attenuate any dysfunctions associated with the corneal endothelium and so preserve maximum visual acuity.

Femtosecond laser-assisted cataract surgery in patients with phakic intraocular lenses and low endothelial cell counts: a case report.

BACKGROUND: Phakic intraocular lens (PIOL) implantation has been used to correct myopia and myopic astigmatism, although corneal decompensation can occur after implantation. Femtosecond laser-assisted cataract surgery (FLACS) has gained in popularity due to its lower postoperative astigmatism and endothelial loss. Herein, we report the use of FLACS in patients who previously received PIOL implantation and have a low corneal endothelial cell count. CASE PRESENTATION: Two patients with a previous iris-claw PIOL implantation were enrolled. The preoperative corrected distance visual acuity (CDVA) and diopter sphere (DS) were 20/32 and -0.25 D in patient 1 and 20/32 and -3.00 D in patient 2. Specular microscope examination revealed an endothelial cell density (ECD) of 1532/mm2 in patient 1 and 1620/mm2 in patient 2. Capsulotomy was performed smoothly using a femtosecond laser. Postoperative CDVA improved in both eyes, with a difference of DS less than 1 D from the preoperative estimation. Specular microscope examination revealed a decreased endothelial cell density (ECD) in patient 2, but no signs of corneal decompensation were detected. CONCLUSIONS: The influence of using PIOL on capsulotomies performed via FLACS, in combination with preoperative refraction calculation, is minimal. A mild decrease in ECD may occur, but there is a low probability of severe corneal decompensation, even in patients with a low endothelial cell count.