Ocular Anterior Segment Pathology in the Emergency Department: A 5-Year Study.

INTRODUCTION: Patients with ocular complaints frequently present to emergency departments (EDs) for care. Emergency department practitioners are often the first to evaluate these patients and determine the next steps in their care, which can be a challenging task. The purpose of this study is to determine the frequency of anterior segment pathology in the setting of the ED in hopes that this information will be useful in creating more effective management algorithms. METHODS: A retrospective study based on electronic patient charts from the University of California Davis ED that included ophthalmology consults. We reviewed the charts for demographic data, as well as visual acuity (VA), intraocular pressure (IOP), and diagnosis as determined by ED and ophthalmology personnel, respectively. RESULTS: The most common anterior segment diagnoses were uveitis, corneal abrasion, corneal ulcer, meibomian gland dysfunction/dry eyes/blepharitis/punctate epithelial erosions, and conjunctivitis/epidemic keratoconjunctivitis. Emergency Department personnel measured the VA and IOP in 40.8% and 16.7% of patients, respectively. The ophthalmologist measured the VA and IOP in 78.4% and 95.1% of patients, respectively. The percentage agreement in VA measurement between ophthalmology and ED was 11.8%. The percentage agreement in IOP measurement between ophthalmology and ED was 0.86%. The percentage agreement in diagnosis between ophthalmology and ED was 49.4%. CONCLUSIONS: Most ocular conditions that present in the ED are nonurgent and can be treated in an outpatient setting. However, ED personnel are often unable to obtain the proper "ocular vital signs" (the VA and IOP) and diagnoses. Our findings suggest a need for clear interprofessional discussion in creating an algorithm for triage and the management of eye conditions in the ED to deliver effective care.

Intraocular methotrexate for epithelial downgrowth: long-term outcomes in a multicentre case series.

BACKGROUND/AIMS: Sheet-like type of epithelial downgrowth (EDG) is not easily amenable to surgical excision. We describe long-term outcomes in patients with EDG treated with intraocular methotrexate (MTX). METHODS: This is a retrospective, multicentric case series including 10 eyes (nine patients) treated with intraocular MTX for sheet-like EDG. Relevant ocular history, previous EDG treatments, MTX injection regimen, long-term outcomes and complications are reported. RESULTS: All cases were associated with intraocular surgery. Most patients were treated with 400 µm/0.1 mL MTX injections with a starting frequency of two times per week or weekly injections. Mean and SD number of injections per eye was 16±13 injections and duration of follow-up was 54±36 months (range: 7-120 months). Eradication of EDG was achieved in seven eyes of which one required a second MTX treatment course to achieve eradication, while clinical resolution with recurrence was observed in two. One treatment failure occurred despite eight weekly injections which slowed but did not halt EDG progression; the patient later requested that treatments be stopped given difficulty to come to follow-ups. Surface epitheliopathy developed in eight patients and was used to titrate MTX treatment. Six patients also developed endothelial failure. CONCLUSION: We report the largest case series of diffuse, sheet-like EDG treated with intraocular MTX with follow-ups up to 10 years. Intraocular MTX may be used effectively to achieve eradication of EDG in cases where surgery is not amenable. However, further recommendations to guide treatment remain warranted.

Review of Corneal Graft Registries.

PURPOSE: Corneal graft registries are organized systems that collect and analyze outcome data (such as long-term graft survival and visual outcomes) after keratoplasty procedures. The aim of this review was to identify existing corneal graft registries and to describe their characteristics. METHODS: A search of the PubMed database was performed on June 1, 2021, for articles pertaining to corneal graft registries. RESULTS: The PubMed literature search yielded 958 publications, of which 116 met all the inclusion and exclusion criteria. Among these articles, 15 corneal graft registries were identified, including 6 regional registries, 8 national registries, and 1 multinational registry. This article provides an overview of their characteristics and discusses the main advantages and pitfalls of clinical registries. CONCLUSIONS: Clinical registry data are increasingly recognized as a valuable tool to monitor corneal transplant outcomes to improve health care services and optimize resource management.

Cultured Autologous Corneal Epithelia for the Treatment of Unilateral Limbal Stem Cell Deficiency: A Case Series of 15 Patients.

Damage to limbal epithelial stem cells can lead to limbal stem cell deficiency (LSCD). Current autologous treatment procedures for unilateral LSCD bear a significant risk of inducing LSCD in the donor eye. This complication can be avoided by grafting a stem cell containing cultured autologous corneal epithelium (CACE). The primary objective of this study was to demonstrate the safety of CACE grafted on eyes with LSCD. The secondary objective was to assess the efficacy of a CACE graft in restoring a self-renewing corneal surface with adequate anatomic structures, as well as improving the best corrected visual acuity (BCVA). Fifteen patients were grafted with a CACE on a fibrin gel produced from a 3 mm2 limbal biopsy harvested from the donor eye. Data were collected at baseline and after grafting. Follow-ups from 1 to 5 years were conducted. No major adverse events related to the CACE graft were observed. For every visit, an anatomic score based on corneal opacity as well as central vascularization and a functional score based on BCVA were determined. Safety was demonstrated by the low occurrence of complications. Anatomical (93%) and functional (47%) results are promising for improving vision in LSCD patients. Combined functional success and partial success rates with inclusion of BCVA were 53% [CI95: 27-79%] one year after CACE grafting. At the last follow-up, 87% [CI95: 60-98%] of the patients had attained corneal clarity. The outcomes demonstrate the safety of our technique and are promising regarding the efficacy of CACE in these patients.

Optimizing Visualization of Descemet Membrane Endothelial Keratoplasty Tissue: Assessing the Impact of Trypan Blue Exposure on Stain Duration and Corneal Endothelial Cell Function.

PURPOSE: To assess how trypan blue staining affects Descemet membrane endothelial keratoplasty (DMEK) graft visibility and corneal endothelial cell (CEC) mitochondrial respiration. METHODS: DMEK grafts (n = 20) were stained with trypan blue 0.06% for 1, 3, 5, or 10 minutes. Each graft was injected into an artificial anterior chamber. Surgery was simulated with tapping and sweeping motions on the corneal surface and injections of balanced salt solution (BSS). Graft visibility was assessed at 5, 10, 20, and 30 minutes. Effects of trypan blue on mitochondrial respiration were assessed using primary CECs cultured from donor corneas (n = 43). Treatment wells exposed to trypan blue 0.06% (1, 5, or 30 minutes) and donor-matched control wells to methylene blue 1% (1 minute) or BSS (1, 5, or 30 minutes) were assayed for key respiration parameters. RESULTS: After 5 minutes of surgical manipulation, grafts stained for 5 minutes were significantly more visible than grafts stained for 1 or 3 minutes; there was no added benefit of staining for 10 minutes. After 10 minutes of surgical manipulation, grafts stained for 3 minutes were more visible than grafts stained for 1 minute, without additional benefits of staining ≥5 minutes. No visibility differences were observed after ≥20 minutes of surgical manipulation. CEC mitochondrial respiration did not change significantly following trypan blue exposure for all intervals tested compared to BSS. CONCLUSIONS: Staining DMEK grafts with trypan blue for 3 to 5 minutes optimizes visibility during surgical manipulation without mitochondrial impairment. Corneal surgeons learning DMEK will benefit from optimizing this critical step.

Keratoconus and Personality-A Review.

PURPOSE: To assess the existing literature on the subject of keratoconus and personality and to propose a theory that might account for the perceived personality changes associated with this condition. METHODS: A literature search was conducted in the PubMed database using the term "keratoconus" in combination with keywords such as personality, psychiatry, psychology, anxiety, depression, or psychosis. A total of 15 articles pertaining to personality and psychiatric disorders in keratoconus were retained and reviewed. RESULTS: Although patients with keratoconus tend to score differently on personality scales compared with normal controls, the literature fails to substantiate the existence of a unique "keratoconic personality." Instead, patients with keratoconus prove to have more dysfunctional coping mechanisms that specifically alter their interaction with health care providers and may account for the persistent clinical impression of less respectful, conforming, and cooperative patients. CONCLUSIONS: We hypothesize that the stage of life at which keratoconus commonly presents plays a crucial role in personality and coping mechanism development that significantly affects behavioral patterns and the relationship with caregivers.

Effect of music on surgical skill during simulated intraocular surgery.

OBJECTIVE: To evaluate the effect of Mozart music compared to silence on anterior segment surgical skill in the context of simulated intraocular surgery. DESIGN: Prospective stratified and randomized noninferiority trial. PARTICIPANTS: Fourteen ophthalmologists and 12 residents in ophthalmology. METHODS: All participants were asked to perform 4 sets of predetermined tasks on the EyeSI surgical simulator (VRmagic, Mannheim, Germany). The participants completed 1 Capsulorhexis task and 1 Anti-Tremor task during 3 separate visits. The first 2 sets determined the basic level on day 1. Then, the participants were stratified by surgical experience and randomized to be exposed to music (Mozart sonata for 2 pianos in D-K448) during either the third or the fourth set of tasks (day 2 or 3). Surgical skill was evaluated using the parameters recorded by the simulator such as "Total score" and "Time" for both tasks and task-specific parameters such as "Out of tolerance percentage" for the Anti-Tremor task and "Deviation of rhexis radius from 2.5 mm," "Roundness," and "Centering" for the Capsulorhexis task. The data were analyzed using the Wilcoxon signed-rank test. RESULTS: No statistically significant differences were noted between exposure and nonexposure for all the Anti-Tremor task parameters as well as most parameters for the Capsulorhexis task. Two parameters for the Capsulorhexis task showed a strong trend for improvement with exposure to music ("Total score" +23.3%, p = 0.025; "Roundness" +33.0%, p = 0.037). CONCLUSION: Exposure to music did not negatively impact surgical skills. Moreover, a trend for improvement was shown while listening to Mozart music.

Prolene monofilament suture in Boston Keratoprosthesis surgery.

Toxic reaction to nylon following uncomplicated cataract surgery and vitrectomy has been documented in the literature. We report the case of an aniridic patient with a known adverse reaction to nylon in whom Prolene suture was used in Boston Keratoprosthesis type 1 (KPro) surgery. During follow-up the cornea was checked for signs of inflammation and toxic reaction; at last follow-up (18 months) the patient showed no signs of complications due to Prolene. Our study suggests that Prolene suture may be used as an alternative to nylon in Boston KPro surgery in patients with a history of nylon toxicity.

A failed corneal graft as a support for the Boston Keratoprosthesis type 1.

The implantation of the Boston Keratoprosthesis (KPro) requires a corneal button, which is usually taken from a donor. Scarcity of donor tissue has been a major limiting factor in transplant surgery. Recently, autologous recipient cornea has been reported as support for the KPro. We report the successful use of an ipsilateral failed corneal graft as the carrier tissue for a patient requiring combined pars plana vitrectomy and KPro implantation.