Short-Term Outcomes of Pediatric Keratoprosthesis With the Near-Complete Conjunctival Flap.

PURPOSE: The Boston keratoprosthesis (KPro) has been used for certain indications in pediatric patients with congenital corneal opacities. Here, we describe the use of a near-complete conjunctival flap at the time of Boston type 1 KPro surgery in pediatric patients, with the goal of improving pediatric KPro outcomes. METHODS: We performed a retrospective chart review of 21 eyes from 16 patients who received their first KPro before the age of 18 years at a tertiary care center in Rochester, NY. Surgeries were performed between 2011 and 2017 (3 years before and after the incorporation of a conjunctival flap, which began in 2014 as part of the pediatric KPro procedure). Patients who had a minimum 1-year postoperative follow-up, or had corneal melts within 1 year of KPro implantation, were included in our study. The main outcome measure in this study was a comparison of the number of complications that required surgical intervention, including retroprosthetic membrane, corneal melt, retinal detachment, and endophthalmitis, in eyes that received KPro implantation without a conjunctival flap compared with eyes that received KPro implantation with a conjunctival flap. Change in the visual acuity up to 1 year postoperatively was also measured. RESULTS: Ten eyes received KPro with no conjunctival flap, and 11 eyes received KPro with a near-complete conjunctival flap. After 1-year postoperative follow-up, eyes receiving a KPro with a conjunctival flap had fewer KPro-related complications requiring surgical intervention (5 vs. 16, P = 0.0002). Corneal melt was seen in 2 of 11 (18%) eyes in the conjunctival flap group and 5 of 10 (50%) eyes in the nonflap group (P = 0.12). No eyes developed endophthalmitis in the flap group, whereas 1 of 10 (10%) eyes developed endophthalmitis in the nonflap group. Visual acuity at 1-year follow-up improved in 9 of 11 (82%) eyes in the flap group compared with 5 of 10 (50%) eyes in the nonflap group (P = 0.3). CONCLUSIONS: Implementation of a conjunctival flap in pediatric KPro may help decrease the short-term postoperative complications requiring surgical procedures and may lead to improved visual acuity after 1 year. Further investigation, including longer-term follow-up, is needed to better understand how the described technique affects surgical outcomes in children.

Seizure symptoms and ambulatory EEG findings: incidence of epileptiform discharges.

AIMS: Ambulatory video-EEG monitoring has been utilized as a cost-effective alternative to inpatient video-EEG monitoring for non-surgical diagnostic evaluation of symptoms suggestive of epileptic seizures. We aimed to assess incidence of epileptiform discharges in ambulatory video-EEG recordings according to seizure symptom history obtained during clinical evaluation. METHODS: This was a retrospective cohort study. We queried seizure symptoms from 9,221 consecutive ambulatory video-EEG studies in 35 states over one calendar year. We assessed incidence of epileptiform discharges for each symptom, including symptoms that conformed to a category heading, even if not included in the ILAE 2017 symptom list. We report incidences, odds ratios, and corresponding p values using Fisher's exact test and univariate logistic regression. We applied multivariable logistic regression to generate odds ratios for the six symptom categories that are controlled for the presence of other symptoms. RESULTS: History that included motor symptoms (OR=1.53) or automatisms (OR=1.42) was associated with increased occurrence of epileptiform discharges, whereas history of sensory symptoms (OR=0.76) predicted lack of epileptiform discharges. Patient-reported symptoms that were associated with increased occurrence of epileptiform discharges included lip-smacking, moaning, verbal automatism, aggression, eye-blinking, déjà vu, muscle pain, urinary incontinence, choking and jerking. On the other hand, auditory hallucination memory deficits, lightheadedness, syncope, giddiness, fibromyalgia and chronic pain predicted absence of epileptiform discharges. The majority of epileptiform discharges consisted only of interictal sharp waves or spikes. CONCLUSIONS: Our study shows that the use of ILAE 2017 symptom categories may help guide ambulatory video-EEG studies.

Outcome of ambulatory video-EEG monitoring in a ˜10,000 patient nationwide cohort.

PURPOSE: We evaluate outcome of in-home diagnostic ambulatory video-EEG monitoring (AVEM) performed on a nationwide cohort of patients over one calendar year, and we compare our findings with outcomes of inpatient adult and pediatric VEM performed during the same year at two academic epilepsy centers. METHODS: This is a retrospective cohort study. We obtained AVEM outcome data from an independent ambulatory-EEG testing facility. Inpatient VEM data from a 4-bed adult epilepsy center and an 8-bed pediatric epilepsy center were also included. Primary outcome measure was composite percentage of VEM records with epileptiform activity on EEG tracings or at least one video-recorded pushbutton event. We assessed patient-reported symptoms documented in AVEM event diaries. RESULTS: Of 9221 AVEM recordings performed across 28 states, 62.5% attained primary outcome. At least one patient-activated pushbutton event was captured on video in 54% of AVEM recordings (53.6% in adults, 56.1% in children). Epileptiform activity was reported in 1657 (18.0%) AVEM recordings (1473 [88.9%] only interictal, 9 [0.5%] only ictal, 175 [10.6%] both interictal and ictal). Most common patient-reported symptomatology during AVEM pushbutton events was behavioral/autonomic/emotional in adults and children. Compared to AVEM, inpatient VEM captured more confirmed representative events in adult and pediatric samples. CONCLUSIONS: AVEM is useful for non-urgent diagnostic evaluation of events.

Association of Intraocular Pressure With Human Immunodeficiency Virus.

PURPOSE: Prior studies have shown an association between human immunodeficiency virus (HIV) and reduced intraocular pressures (IOP). The purpose of this study was to determine if patients with HIV on highly active antiretroviral therapy (HAART) had any difference in their IOP compared with patients without HIV or with HIV who are not on HAART. DESIGN: Retrospective cross-sectional study. METHODS: We included 400 patients from our academic eye center between 2000 and 2016. Group 1 (G1) consisted of patients with HIV on HAART (n = 176), Group 2 (G2) consisted of patients with HIV who were not on HAART (n = 48), and Group 3 (G3) consisted of controls without HIV (n = 176). An analysis of variance (ANOVA) was performed to compare mean IOP values. Multivariate linear and logistic regression models were performed to assess factors impacting IOP. Difference in IOP was the primary outcome being measured. RESULTS: The mean IOPs in mm Hg were 13.7 ± 5.1 (G1), 13.1 ± 3.6 (G2), and 17.3 ± 3.8 (G3), P < .01. In regression modeling, having a CD4 count ≤700 cells/mm3 contributed to a 2.1 mm Hg decrease in IOP. Patients with HIV were 7 times more likely to have an IOP ≤10 mm Hg, and patients with a CD4 count ≤700 cells/mm3 were 13 times more likely to have an IOP ≤10 mm Hg. CONCLUSIONS: Absolute CD4 counts may play a role in IOP fluctuations. This association was found in patients with HIV regardless of whether patients were on HAART.

Factors affecting successful isolation of human corneal endothelial cells for clinical use.

Corneal transplantation is a common transplant procedure used to improve visual acuity by replacing the opaque or distorted host tissue with clear healthy donor tissue. However, its clinical utility is limited due to a lack of donor supply of high-quality corneas. Bioengineered neocorneas, created using an expandable population of human donor-derived corneal endothelial cells (HCECs), could address this shortage. Thus, the objective of this study was to evaluate HCEC sourcing with various isolation methods, including enzymatic digestion, culture medium components, and adhesive proteins. HCECs were obtained from corneas obtained from various aged donors after endothelial keratoplasty. Under a dissection microscope, the Descemet's membrane, including the attached corneal endothelium, was stripped from the stroma, and the cells were isolated and expanded by explant culture or by enzymatic digestion with enzymes such as collagenase II, dispase, or trypsin. In order to improve the initial cell attachment, tissue culture plates were coated with collagen IV, fibronectin, or fibronectin-collagen combination coating mix (FNC) before cell plating. We were able to successfully obtain HCECs from 32% (86/269) of donor corneas. Donor age and isolation method influenced the characteristics of the resulting in vitro HCEC culture. Under all conditions tested, FNC-coated plates showed higher quality cultures than the other coatings tested. These results suggest that donor age and HCEC isolation methodology are the two factors that most directly affect the quality of the resulting HCEC culture in vitro. These factors should guide the methodological development for the clinical expansion of HCECs for the generation of bioengineered neocorneas.

In vitro evaluation of the interactions between human corneal endothelial cells and extracellular matrix proteins.

The corneal endothelium is the innermost cell layer of the cornea and rests on Descemet's membrane consisting of various extracellular matrix (ECM) proteins which can directly affect the cellular behaviors such as cell adhesion, proliferation, polarity, morphogenesis and function. The objective of this study was to investigate the interactions between the ECM environment and human corneal endothelial cells (HCECs), with the ultimate goal to improve cell proliferation and function in vitro. To evaluate the interaction of HCECs with ECM proteins, cells were seeded on ECM-coated tissue culture dishes, including collagen type I (COL I), collagen type IV (COL IV), fibronectin (FN), FNC coating mix (FNC) and laminin (LM). Cell adhesion and proliferation of HCECs on each substratum and expression of CEC markers were studied. The results showed that HCECs plated on the COL I, COL IV, FN and FNC-coated plates had enhanced cell adhesion initially; the number for COL I, COL IV, FN and FNC was significantly higher than the control (P < 0.05). In addition, cells grown on ECM protein-coated dishes showed more compact cellular morphology and CEC marker expression compared to cells seeded on uncoated dishes. Collectively, our results suggest that an adequate ECM protein combination can provide a long-term culture environment for HCECs for corneal endothelium transplantation.