Dysfunctional tear syndrome: dry eye disease and associated tear film disorders - new strategies for diagnosis and treatment.

Dysfunctional tear syndrome (DTS) is a common and complex condition affecting the ocular surface. The health and normal functioning of the ocular surface is dependent on a stable and sufficient tear film. Clinician awareness of conditions affecting the ocular surface has increased in recent years because of expanded research and the publication of diagnosis and treatment guidelines pertaining to disorders resulting in DTS, including the Delphi panel treatment recommendations for DTS (2006), the International Dry Eye Workshop (DEWS) (2007), the Meibomian Gland Dysfunction (MGD) Workshop (2011), and the updated Preferred Practice Pattern guidelines from the American Academy of Ophthalmology pertaining to dry eye and blepharitis (2013). Since the publication of the existing guidelines, new diagnostic techniques and treatment options that provide an opportunity for better management of patients have become available. Clinicians are now able to access a wealth of information that can help them obtain a differential diagnosis and treatment approach for patients presenting with DTS. This review provides a practical and directed approach to the diagnosis and treatment of patients with DTS, emphasizing treatment that is tailored to the specific disease subtype as well as the severity of the condition.

Comparing the time efficiency of two lasers used in FLACS: real-world observational study.

PURPOSE: To evaluate time efficiencies in the laser room for 2 different femtosecond laser systems. SETTING: 1 private practice in Atlanta, Georgia, and 1 private practice in Los Angeles, California. DESIGN: Prospective, observational, single-masked study. METHODS: Patients scheduled to receive femtosecond laser-assisted cataract surgery (FLACS) included those who were not pregnant, had no previous eye surgeries, and were not scheduled to undergo additional surgical procedures at the time of treatment; patients who received a standard, monofocal lens without undergoing arcuate incisions were excluded. Patients taking Flomax or any tamsulosin were also excluded from the study. Each comparable step in the LenSx and CATALYS workflow was identified and clearly defined. Time for each step was evaluated and compared using t tests and regression analyses to control for patient and site-specific differences between the 2 groups. RESULTS: Time data were collected for 89 patients (89 eyes). The overall procedure was 2.86 minutes shorter for the LenSx system when compared with the CATALYS system ( P < .05). Per patient, the LenSx system had significantly shorter time for patient positioning (57.26 vs 122.00 seconds; P < .05), imaging (33.23 vs 42.17 seconds; P < .05), laser treatment (21.57 vs 39.67 seconds; P < .05), and undocking/transition (67.13 vs 185.30 seconds; P < .05) compared with the CATALYS system. Regression analyses yielded similar results, with the LenSx system being over 35% (3.21 minutes; P < .05) shorter overall than the CATALYS system controlling for location, age, sex, lens thickness, cataract grade, fragmentation pattern, and arcuate incisions. CONCLUSIONS: LenSx procedures were significantly shorter than the CATALYS procedures overall, which can enable ophthalmology practices to increase efficiency.

Three-year visual acuity outcomes after Descemet's stripping automated endothelial keratoplasty.

PURPOSE: To evaluate the long-term improvement of visual acuity after Descemet's stripping automated endothelial keratoplasty (DSAEK) surgery. DESIGN: Retrospective analysis of a noncomparative, interventional case series. PARTICIPANTS: One hundred eight patients undergoing DSAEK surgery for Fuchs' endothelial dystrophy and pseudophakic bullous keratopathy without other ocular comorbidities who completed a full 3-year follow-up period. METHODS: Postoperative best spectacle-corrected visual acuity (BSCVA) was recorded at 6, 12, 24, and 36 months. Improvement in BSCVA between each time point was evaluated using paired-samples t tests. Subanalysis evaluating the percentage of eyes achieving a BSCVA of 20/20, 20/25, 20/30, and 20/40 at each time point was performed. MAIN OUTCOME MEASURES: Improvement in postoperative BSCVA. RESULTS: There was a statistically significant trend toward improvement in average BSCVA with time at postoperative month 6 and postoperative years 2 and 3. There were also increasing proportions of eyes reaching vision of 20/20, 20/25, and 20/30 from 6 months to 1 year, 1 year to 2 years, and 2 years to 3 years. The percentage of patients achieving 20/25 BSCVA improved from 36.1% at 6 months to 70.4% at 3 years after surgery. A similar increase in the percentage of patients reaching a BSCVA of 20/20 after DSAEK surgery also was observed from 11.1% at 6 months to approximately 47.2% at 3 years. CONCLUSIONS: There is gradual improvement of visual acuity over time after DSAEK surgery for Fuchs' endothelial dystrophy and pseudophakic bullous keratopathy in patients without other vision-limiting ocular comorbidities. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Graft rejection after Descemet's stripping automated endothelial keratoplasty: graft survival and endothelial cell loss.

PURPOSE: To evaluate the effects of graft rejection episodes after Descemet's stripping automated endothelial keratoplasty surgery (DSAEK) on long-term endothelial cell density (ECD) decline and graft survival. DESIGN: Retrospective, comparative analysis of an interventional case series. PARTICIPANTS: We included 615 eyes of 415 Fuchs' dystrophy patients at a single institution with ≥ 6 months follow-up and without comorbidities known to influence postoperative ECD. All patients were enrolled as part of an ongoing, institutional review board-approved clinical protocol for a long-term, prospective study of endothelial keratoplasty in patients with endothelial dysfunction. METHODS: Preoperative specular microscopy of donor corneal tissue was performed. Postoperative specular microscopy measurements were recorded at 6 and 12 months, and yearly thereafter. The percentages of endothelial cell loss recorded at 1, 2, 3, and 4 years were compared with the Mann-Whitney U test. MAIN OUTCOME MEASURES: Percentage ECD declines were calculated at each time point from the results of the preoperative and postoperative specular microscopy. Patients with graft rejection episodes and late endothelial failure were identified. Graft rejection was defined as findings of keratic precipitates with or without corneal edema, or anterior chamber cell and flare with or without corneal edema after the initial resolution of perioperative inflammation. RESULTS: We identified 45 cases of graft rejection. The greatest number of rejections occurred between postoperative months 12 and 18. Eyes with a graft rejection episode had a higher median percentage decline in ECD at all time points compared with eyes without graft rejection episodes. This was statistically significant at 2 and 3 years postoperatively. CONCLUSIONS: There is a trend toward a greater percentage of ECD loss with time in eyes experiencing graft rejection after DSAEK surgery. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Navigating Personal and Professional Development Through Social Media in Ophthalmology.

Background: Although social media use among physicians skyrocketed during the COVID-19 pandemic, its role for networking, mentorship, and support among ophthalmologists remains unknown. The objective of this study was to elucidate how ophthalmologists use social media for navigating challenges related to personal and professional development. Methods: This was a cross-sectional survey study conducted during the height of the COVID-19 pandemic. A 40-item questionnaire investigating the usage of social media was developed and distributed to active social media users in ophthalmology including trainees and practitioners from November 2020 to December 2020 via social media channels. Quantitative responses were analyzed using descriptive and basic statistics, while a thematic analysis was conducted to examine the qualitative responses. Results: One hundred and forty-nine respondents (67% women) completed the survey, with 56% of participants between the ages of 25-35 years old. Women were more likely to report experiencing workplace discrimination (p < 0.005) and work-life imbalance (p < 0.05) compared to men, and social media was found to be useful in addressing those challenges in addition to parenting and mentorship (p < 0.005 and p < 0.001, respectively). Compared to their older counterparts, younger ophthalmologists (<45 years old) cited more challenges with practice management (p < 0.005) and turned to social media for corresponding guidance (p < 0.05). Compared to late career ophthalmologists, trainees were more likely to report difficulties with career development (p < 0.05), practice management (p < 0.0001), and financial planning (p < 0.05), and found social media beneficial for learning financial literacy (p < 0.05). A qualitative analysis of the free-response texts found both positive and negative viewpoints of social media use in ophthalmology. Conclusion: Social media is an invaluable tool for enhancing professional and personal growth for ophthalmologists, particularly for women, trainees, and younger surgeons through education and community-building. Future directions include exploring how social media can be used to improve mentorship, outreach, and training in ophthalmology.

Endothelial keratoplasty: the relationship between donor tissue storage time and donor endothelial survival.

PURPOSE: To evaluate the relationship between storage time in Optisol GS (Bausch & Lomb, St. Louis, MO) and postoperative cell loss after Descemet's stripping automated endothelial keratoplasty (DSAEK) surgery. DESIGN: Retrospective analysis of a noncomparative, interventional case series. PARTICIPANTS: Three hundred sixty-two eyes of 265 patients undergoing DSAEK surgery for Fuchs' endothelial dystrophy. METHODS: Storage times (death to surgery) of donor tissue were recorded for 362 eyes undergoing DSAEK surgery. Donor cell loss at 6, 12, and 24 months was recorded. Analysis of storage times with endothelial cell loss was performed using a Pearson correlation coefficient and an independent samples Student t test. MAIN OUTCOME MEASURES: Percentage of donor endothelial cell loss as measured by specular microscopy of central endothelial cell density (ECD). RESULTS: The mean storage time was 98.95 ± 33 hours (range, 20.65-186.02 hours). The mean percent endothelial cell loss from before to after surgery was 29 ± 16% at 6 months (n = 362), 31 ± 16% at 12 months (n = 263), and 32 ± 20% at 24 months (n = 98). Storage time did not correlate significantly with endothelial cell loss at any postoperative time point (6 months: r = -0.047, P = 0.373; 12 months: r = -0.023, P = 0.709; 24 months: r = -0.14, P = 0.169). The mean cell loss for corneas stored 0 to 4 days (n = 55) was 32 ± 17% at 2 years and the mean cell loss for corneas stored for more than 4 days (n = 43) was 30 ± 18% at 2 years (P = 0.57). At the extremes of storage time, 10 corneas stored for the shortest time (1.5 days) had a 1-year cell loss of 33% and 10 corneas stored for the longest time (7 days) had a 1-year cell loss of 30% (P = 0.45). CONCLUSIONS: No correlation was found between the characteristic of storage time and the decline of ECD. Surgeons should not make special requests to the eye bank for short storage times with the hope of improving donor endothelial survival. The upper limit of donor storage time as it relates to acceptable postoperative endothelial cell loss is not known.

Precut tissue for Descemet's stripping automated endothelial keratoplasty: vision, astigmatism, and endothelial survival.

PURPOSE: To report 6 and 12 month results using precut tissue for Descemet's stripping automated endothelial keratoplasty (DSAEK) and correlate donor characteristics with clinical outcomes. DESIGN: Prospective, noncomparative, interventional case series. PARTICIPANTS: We reviewed 100 donor corneas precut for 100 eyes of 90 DSAEK patients. METHODS: Our first 100 consecutive cases of DSAEK with precut tissue were entered into a prospective protocol. Donor characteristics and the visual, refractive, topographic, and specular microscopy results at 6 and 12 months were analyzed. Correlation analysis comparing donor characteristics with clinical outcomes was performed. MAIN OUTCOME MEASURES: Six- and 12-month postoperative best spectacle-corrected visual acuity (BSCVA), refractive astigmatism, topographic keratometry (K), and specular endothelial cell densities (ECD) were measured prospectively and then compared with preoperative values. Donor characteristics analyzed included death to preservation time, death to surgery time, precutting resection to surgery time, and graft thickness. RESULTS: Six months after DSAEK surgery, BSCVA improved from 20/83 to 20/38. (P<0.01). In eyes with no known comorbidity (n = 60), 92% had a vision of >/=20/40 at 6 months and 20% obtained > or =20/20. Astigmatism changed an average of 0.09 diopters (D) and K changed by +0.09 D, both of which were not significant and were stable to 12 months. The postoperative mean ECD (n = 65) was 1918 cells/mm(2) at 6 months, and represented a 31% cell loss from preoperatively (P<0.001). The mean ECD (n = 61) was 1990 cells/mm(2) at 12 months, and represented a 29% cell loss from preoperatively (P<0.001) with no significant change from 6 to 12 months (P = 0.172). Improvement of visual acuity from preoperative to postoperative in eyes without comorbidity was not correlated with any donor characteristic. Greater endothelial cell loss correlated with higher preoperative ECD levels (P<0.001) and with a trend toward longer precut resection to surgery times at both 6 months (P = 0.049) and 12 months (P = 0.051). CONCLUSIONS: Precut tissue by Eye Banks for use in DSAEK surgery provides an improvement in vision with no significant change in astigmatism. Donor endothelial cell loss from 6 to 12 months is stable and is comparable with reports involving tissue that is cut intraoperatively. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosures may be found after the references.

Endothelial keratoplasty for Fuchs' dystrophy with cataract: complications and clinical results with the new triple procedure.

PURPOSE: To report the immediate postoperative complications and the 6- and 12-month clinical results in a large series of cases undergoing the new triple-procedure Descemet's stripping automated endothelial keratoplasty (DSAEK) and concurrent cataract surgery. DESIGN: Prospective, noncomparative, interventional case series. PARTICIPANTS: Three hundred fifteen eyes of 233 patients with Fuchs' corneal dystrophy were evaluated for the complications of dislocation and iatrogenic primary graft failure (IPGF). Two hundred three eyes of 149 patients had 6-month postoperative data available for other outcome analysis. METHODS: A standardized technique of DSAEK with extensive use of cohesive viscoelastic was performed in all 315 eyes with Fuchs' dystrophy, and 225 of those eyes had cataract surgery concurrently. Of the 203 eyes with 6-month data, concurrent phacoemulsification with intraocular lens placement (triple procedure) was performed in 149 of those eyes. MAIN OUTCOME MEASURES: The complications of graft dislocation and IPGF were recorded for all eyes. Six- and 12-month postoperative best spectacle-corrected visual acuity (BSCVA), refractive spherical equivalent (SE), and central donor endothelial cell density (ECD) were measured prospectively and then compared with preoperative values for the triple-procedure eyes. RESULTS: There were 4 dislocations (4%) among the 90 straight DSAEK cases and 4 dislocations (1.8%) among the 225 triple-procedure cases (P = 0.327). There was not a single case of IPGF in any of the 315 DSAEK cases. After the triple procedure, the BSCVA in eyes without comorbidity (n = 122) improved with 93% at 20/40 or better at 6 months and 97% at 20/40 or better at 12 months. Refractive SE at 6 months averaged 0.11+/-1.08 diopters (D), with 73% of eyes within 1 D of emmetropia and 95% within 2 D of emmetropia. The postoperative mean ECD was 1955 cells/mm(2) at 6 months (n = 125) and 1979 cells/mm(2) at 12 months (n = 89) and represented a 32% cell loss from that before surgery (P<0.001) for both postoperative time points. CONCLUSIONS: The new triple-procedure DSAEK combined with cataract surgery provides rapid visual recovery and allows selection of an appropriate intraocular lens. Dislocations are rare (1.8%) and primary graft failure did not occur.

Effect of Graft Attachment Status and Intraocular Pressure on Descemet Stripping Automated Endothelial Keratoplasty Outcomes in the Cornea Preservation Time Study.

PURPOSE: To examine the association of donor, recipient, and operative factors on graft dislocation after Descemet stripping automated endothelial keratoplasty (DSAEK) in the Cornea Preservation Time Study (CPTS) as well as the effects of graft dislocation and elevated IOP on graft success and endothelial cell density (ECD) 3 years postoperatively. DESIGN: Cohort study within a multi-center, double-masked, randomized clinical trial. METHODS: 1090 individuals (1330 study eyes), median age 70 years, undergoing DSAEK for Fuchs endothelial corneal dystrophy (94% of eyes) or pseudophakic or aphakic corneal edema (6% of eyes). Recipient eyes receiving donor corneal tissue randomized by preservation time (PT) of 0-7 days (N = 675) or 8-14 days (N = 655) were monitored for early or late graft failure through 3 years. Donor, recipient, operative, and postoperative parameters were recorded including graft dislocation (GD), partial detachment, and pre- and post-operative IOP. Pre- and postoperative central donor ECD were determined by a central image analysis reading center. Proportional hazards, mixed effects, and logistic regression models estimated risk ratios and (99% confidence intervals). RESULTS: Three independent predictive factors for GD were identified: a history of donor diabetes (odds ratio [OR]: 2.29 [1.30, 4.02]), increased pre-lamellar dissection central corneal thickness (OR: 1.13 [1.01, 1.27] per 25µ increase), and operative complications (OR: 2.97 [1.24, 7.11]). Among 104 (8%) eyes with GD, 30 (28.9%) developed primary donor or early failure and 5 (4.8%) developed late failure vs. 15 (1.2%; P < .001) and 29 (2.4%; P = .04), respectively, of 1226 eyes without GD. 24 (2%) of 1330 study eyes had early acutely elevated postoperative IOP that was associated with a higher risk of graft failure through 3 years (hazard ratio: 3.42 [1.01, 11.53]), but not with a lower mean 3-year ECD (mean difference 61 (-479, 601) cells/mm2, P = .77). History of elevated postoperative IOP beyond 1 month was not significantly associated with 3-year graft success or ECD. CONCLUSIONS: Donor diabetes, increased donor corneal thickness, and intraoperative complications were associated with an increased risk of GD. Early acutely elevated postoperative IOP and GD significantly increased the risk for graft failure following DSAEK.

Endothelial cell loss after Descemet's stripping endothelial keratoplasty in a large prospective series.

PURPOSE: To report the donor endothelial cell loss in the first year after Descemet's stripping endothelial keratoplasty (DSEK) for the treatment of endothelial dysfunction. DESIGN: Prospective noncomparative interventional case series. PARTICIPANTS: Eighty eyes of 78 patients with corneal edema. METHODS: Eighty eyes with endothelial failure were entered into a prospective study of endothelial keratoplasty (EK). The donor central endothelial cell density (ECD) was recorded postoperatively at 6 months (n = 80) and 12 months (n = 80) and then compared with the preoperative eye bank measurements. The subsets of eyes with the donor prepared manually (DSEK; n = 19) and the donor prepared with a microkeratome (Descemet's stripping automated EK [DSAEK]; n = 61) were also evaluated and compared. MAIN OUTCOME MEASURES: Preoperative and postoperative central ECDs were prospectively evaluated and the cell loss calculated for each postoperative time point. RESULTS: The average and standard deviation ECD at 6 months was 1908+/-354 cells/mm(2), representing a mean cell loss from preoperative donor cell measurements of 34+/-12%. At 12 months, ECD was 1856+/-371 cells/mm(2) (35+/-13% cell loss). The 1% additional cell loss from 6 to 12 months was not significant (P = 0.233). In the subset of DSEK eyes (n = 19), the cell loss from preoperatively to 6 months was 34%, and at 12 months it was 39%. In the subset of DSAEK eyes (n = 61), the cell loss from preoperatively to 6 months was 34%, and at 12 months it was 34%. There was no statistical difference between the cell loss from DSEK and that from DSAEK at 6 months (P = 0.884) or at 12 months (P = 0.224). CONCLUSIONS: Descemet's stripping EK using our surgical technique has a mean donor endothelial cell loss of 34% at the 6-month postoperative examination, and this average cell loss remains relatively stable up to at least 1 year. We found no difference in cell loss between the DSEK and DSAEK techniques over this 1-year postoperative period.

Precut tissue in Descemet's stripping automated endothelial keratoplasty donor characteristics and early postoperative complications.

PURPOSE: To describe donor characteristics of eye bank-prepared precut tissue used in Descemet's stripping automated endothelial keratoplasty (DSAEK) and report any increase in immediate postoperative complications associated with its use. DESIGN: Prospective, noncomparative, interventional case series. PARTICIPANTS: One hundred donor corneas deemed appropriate for transplant and 100 eyes undergoing DSAEK for endothelial dysfunction. METHODS: Precut donor tissue was evaluated in a prospective study of 100 consecutive cases of DSAEK surgery. Donor characteristics and the immediate postoperative complications of donor tissue dislocation and graft failure with the use of precut tissue were recorded and analyzed. MAIN OUTCOME MEASURES: Preoperative donor characteristics (age, time from death to preservation, time from death to implantation, time from cut to implantation, residual stromal bed thickness, pre- and postcut endothelial density), rate of dislocation, and rate of primary graft failure. RESULTS: Average donor age was 57.6+/-10.8 years, average time from death to preservation was 9.8+/-3.2 hours, average time from death to implantation was 94.5+/-33.5 hours, and average time from cut to implantation was 26.0+/-17.4 hours. The average residual stromal bed thickness was 169+/-36 microns. The average endothelial cell density (ECD) after cutting was 2709+/-292 cells/mm(2) (n = 100). In the subgroup of donors in whom pre-resection and postresection endothelial cell densities were available (n = 80), the average ECD before cutting was 2743+/-253 cells/mm(2) and the average ECD after cutting was 2644+/-257 cells/mm(2). This average cell loss of 3.7% was statistically significant (P<0.001). There was only 1 dislocation in this entire series of 100 eyes. There were no primary graft failures. CONCLUSION: The use of precut tissue in DSAEK had a low rate of early postoperative complications such as graft dislocation (1%) and primary graft failure (0%). A wide range of donor characteristics such as donor age, death to transplantation time, precutting to transplantation time, and donor lenticule thickness resulted in excellent adhesion of the tissue and clear grafts.

Endothelial keratoplasty a simplified technique to minimize graft dislocation, iatrogenic graft failure, and pupillary block.

PURPOSE: Endothelial keratoplasty is an exciting alternative to full-thickness penetrating keratoplasty for replacing the diseased endothelium, yet 3 of the major complications seen are dislocation of the donor tissue, primary graft failure (PGF), and pupillary block from the residual, supportive air bubble. Surgical strategies were developed to reduce the likelihood of occurrence of these complications in our first 200 consecutive Descemet's stripping automated endothelial keratoplasty (DSAEK) cases. DESIGN: Prospective, noncomparative, interventional case series. PARTICIPANTS: Two hundred eyes of 172 patients with corneal edema. METHODS: An institutional review board-approved, prospective protocol of endothelial keratoplasty was initiated. Four different surgeons performed DSAEK for the initial 200 consecutive cases using a technique of peripheral recipient bed scraping for donor edge adherence and leaving a residual supportive air bubble, which was freely mobile, and

Isolation of progenitor cells from GFP-transgenic pigs and transplantation to the retina of allorecipients.

Work in rodents has demonstrated that progenitor transplantation can achieve limited photoreceptor replacement in the mammalian retina; however, replication of these findings on a clinically relevant scale requires a large animal model. To evaluate the ability of porcine retinal progenitor cells to survival as allografts and integrate into the host retinal architecture, we isolated donor cells from fetal green fluorescent protein (GFP)-transgenic pigs. Cultures were propagated from the brain, retina, and corneo-scleral limbus. GFP expression rapidly increased with time in culture, although lower in conjunction with photoreceptor markers and glial fibrillary acid protein (GFAP), thus suggesting downregulation of GFP during differentiation. Following transplantation, GFP expression allowed histological visualization of integrated cells and extension of fine processes to adjacent plexiform layers. GFP expression in subretinal grafts was high in cells expressing vimentin and lower in cells expressing photoreceptor markers, again consistent with possible downregulation during differentiation. Cells survived transplantation to the injured retina of allorecipients at all time points examined (up to 10 weeks) in the absence of exogenous immune suppression without indications of rejection. These findings demonstrate the feasibility of allogeneic progenitor transplantation in a large mammal and the utility of the pig in ocular regeneration studies.

Descemet-stripping endothelial keratoplasty: improvement in vision following replacement of a healthy endothelial graft.

We describe a case of endothelial graft exchange in a patient who had inadequate vision without a clinically identifiable cause following Descemet-stripping endothelial keratoplasty (DSEK). The initial DSEK was performed with a hand-dissected donor, and the replacement graft was prepared with an automated microkeratome. The best spectacle-corrected visual acuity (BSCVA) improved from 20/50 before replacement to 20/25 after replacement. Although DSEK provides rapid recovery of excellent vision, few patients achieve a BSCVA of 20/20. Some have substandard vision with no clinically identifiable cause. This case demonstrates that replacing a hand-prepared graft with an automated microkeratome-prepared graft may improve vision in patients with no identifiable cause for visual loss.

Transscleral sulcus fixation of a small-diameter iris-diaphragm intraocular lens in combined penetrating keratoplasty and cataract extraction for correction of traumatic cataract, aniridia, and corneal scarring.

We present the case of a 36-year-old Hispanic man who presented with photophobia and hand motion acuity from a lacerated cornea. Primary repair had been performed 13 years earlier. In addition to a densely scarred cornea and a fibrotic, partially resorbed cataract, more than 300 degrees of iris loss was noted. The patient was treated with penetrating keratoplasty, cataract extraction, and implantation of a transsclerally fixated, small-diameter aniridic intraocular lens (IOL). Despite the significant iris loss, a small-diameter IOL was chosen over a standard larger aniridic IOL to allow safer, more controlled insertion through an 8.0 mm trephination. Following surgery, the visual acuity improved to 20/25 with no symptoms of glare or photophobia.

Endothelial keratoplasty: improvement of vision after healthy donor tissue exchange.

OBJECTIVE: To report 3 cases of graft exchange by using a microkeratome-prepared donor tissue in place of a manually prepared donor tissue for inadequate postoperative visual acuity after deep lamellar endothelial keratoplasty and to discuss possible etiologies. METHODS: Prospective, observational case series. The patients were 3 consecutive patients who underwent endothelial graft replacement for unsatisfactory vision after initial deep lamellar endothelial keratoplasty. This is a review of clinical findings in 3 cases of endothelial keratoplasty that underwent graft exchange for unacceptable vision after deep lamellar endothelial keratoplasty. RESULTS: Two patients benefited from graft exchange by using a microkeratome-prepared donor in place of a manually prepared donor with improvement in best spectacle-corrected visual acuity and 1 did not because of recipient bed irregularities. Vision improved in this patient with penetrating keratoplasty. CONCLUSIONS: Endothelial keratoplasty results in rapid visual recovery and excellent vision. However, fewer eyes achieve 20/20 vision than with full-thickness penetrating keratoplasty. This report shows that some patients with suboptimal vision after endothelial keratoplasty felt to be caused by interface optical problems may benefit from either graft exchange or penetrating keratoplasty.

Use of hyaluronic acid gel filler to improve contact lens wear in patients with deep sunken superior sulcus.

PURPOSE: Deep sunken superior sulcus of the upper eyelid can result from aging, genetic, prostaglandin use, and prior aggressive upper blepharoplasty. If severe, it can cause exposure keratopathy, lagophthalmos, and giant fornix syndrome. We herein report on another milder manifestation of deep superior sulcus and its treatments. METHODS: Case report. RESULTS: Deep sunken superior sulcus syndrome caused to soft contact lens displacement and wear intolerance and was treated with upper eyelid suclus hyaluronic acid gel injection. CONCLUSIONS: Contact lens wear intolerance is likely more common in patients with deep sunken superior sulcus syndrome and can potentially be treated with superior sulcus hyaluronic acid gel injection.

Endothelial keratoplasty: first report of a ruptured globe after deep lamellar endothelial keratoplasty.

PURPOSE: To report a case of ruptured globe after endothelial keratoplasty. METHODS: Review of clinical findings in an 80-year-old man who presented with globe rupture after blunt trauma 3 years after deep lamellar endothelial keratoplasty. RESULTS: The rupture occurred through the temporal scleral tunnel incision with expulsion of endothelial graft and intraocular lens. Primary repair was successful, but the postoperative course has remained complicated. CONCLUSIONS: A ruptured globe caused by blunt trauma can occur after endothelial keratoplasty as it can after other intraocular procedures. In this case, the endothelial graft was extruded with separation of the donor-graft interface. The incidence has yet to be determined and whether it is less than that after standard penetrating keratoplasty surgery will require further long-term studies.

Surgical techniques and adjuvants for the management of primary and recurrent pterygia.

The removal and rate of recurrence of pterygium have been discussed for years. The disorder is highly associated with environmental factors, and recurrence rates can be unacceptably high and cannot be successfully predicted. New techniques and graft preparations and postoperative management strategies are helping to reduce the recurrence rates and provide an ocular surface that is near ideal for future cataract or refractive surgery. This review discusses the advantages and disadvantages of various treatment strategies.