Descemet-Stripping Automated Endothelial Keratoplasty.

PURPOSE: To evaluate the speed of visual recovery in 16 consecutive patients with corneal endothelial dysfunction who received Descemetstripping automated endothelial keratoplasty (DSAEK). METHODS: This is a retrospective study of a novel method for smallincision endothelial transplantation (DSAEK). Endothelial replacement was accomplished with Descemet stripping of the recipient and insertion of a posterior donor tissue that had been prepared with a microkeratome. Best spectacle-corrected visual acuity (BSCVA) by manifest refraction, endothelial counts, and dislocation rates were measured up to 12 months after DSAEK. RESULTS: Sixteen consecutive patients underwent uncomplicated DSAEK. Three patients had known optic nerve or macular disease precluding vision better than 20/200. Of the remaining 14 patients, 11 had BSCVA of 20/40 by postoperative week 12 (7 by week 6). The remaining 2 were 20/50 by weeks 6 and 12. All 14 patients were 20/40 or better at 1 year. One patient had a primary graft failure, and surgery was repeated with 20/40 BSCVA at 1 year. The dislocation rate was 25%. The average cell count between 7 and 10 months was 1714. The average pachymetry was 682. CONCLUSION: DSAEK surgery allows rapid, excellent BSCVAvisual recovery. The rate of visual recovery is more rapid than usually found with penetrating keratoplasty.

Recovery of Contrast Sensitivity After Descemet Membrane Endothelial Keratoplasty.

PURPOSE: To study the change in contrast sensitivities in eyes with Fuchs endothelial dystrophy and bullous keratopathy after Descemet membrane endothelial keratoplasty (DMEK). METHODS: In this prospective study, 50 pseudophakic eyes of 50 patients who received DMEK surgery at the Charité-Universitätsmedizin Berlin were included. Visual acuity; contrast sensitivity using OPTEC 6500 at spatial frequencies of 1.5, 3, 6, 12, and 18 cycles/degree in photopic and mesopic light with and without glare; central corneal thickness (CCT); and anterior and posterior corneal aberrations were measured preoperatively and at 3 and 12 months postoperatively. RESULTS: Best-corrected visual acuity (preoperative 0.67 ± 0.46 and after 12 months 0.19 ± 0.16 LogMAR, P < 0.001) and photopic and mesopic contrast sensitivities with and without glare improved significantly, whereas CCT decreased significantly (preoperative 677 ± 114 µm, after 12 months 527 ± 29 µm, P < 0.001). Preoperative CCT correlates significantly with preoperative photopic contrast sensitivity (correlation coefficient -0.462, P = 0.002), and postoperative total anterior aberrations correlates with postoperative photopic contrast sensitivity (correlation coefficient -0.361, P = 0.006). CONCLUSIONS: Photopic and mesopic contrast sensitivities, especially with glare, are impaired in patients with Fuchs endothelial dystrophy and bullous keratopathy. The extent of the corneal thickening seems to mainly influence the contrast sensitivity preoperatively. DMEK surgery improves the contrast sensitivity significantly. However, higher postoperative anterior corneal aberrations limit the postoperative contrast sensitivities.

Techniques, Outcomes, and Complications of Preloaded, Trifolded Descemet Membrane Endothelial Keratoplasty Using the DMEK EndoGlide.

PURPOSE: To describe 2 insertion techniques, outcomes, and complications of preloaded, trifolded Descemet membrane endothelial keratoplasty (DMEK) cases using the DMEK EndoGlide inserter. METHODS: This retrospective, consecutive case series analyzed the first 35 cases using the DMEK EndoGlide performed between October 2018 and October 2019 at a single center. Preloaded, trifolded DMEK tissues were delivered through a fluid-injected or pull-through technique. To inject the tissue, a burst of fluid was delivered into the lumen of the injector with a second instrument. Postoperatively, best-spectacle corrected visual acuity (BSCVA), pachymetry, graft survival, and complications were assessed. RESULTS: Thirty-five eyes of 29 patients underwent DMEK alone (n = 11), with cataract surgery (n = 21), or with additional surgeries (n = 3). Of these, 19 (54.3%) grafts were injected. Video analysis revealed a median time of 3.5 minutes from graft insertion to opening for gas insertion. Median preoperative BSCVA of 0.398 logMAR improved to 0.097 logMAR (P = 0.02) at 9 months. Median pachymetry decreased from 619 µm to 551 µm (P = 0.03) at 9 months. Median donor endothelial cell count of 2890.5 cells/mm2 reduced to 2123 cells/mm2 (26.6% endothelial cell loss; P = 0.008) 6 months postoperatively. One (2.9%) graft failed due to inverted marking at the eye bank and subsequent reverse implantation. CONCLUSIONS: Pre-loaded, tri-folded tissues can be implanted with acceptable levels of endothelial cell loss. We describe a no-touch method of injecting pre-loaded, tri-folded tissue and highlight incorrect marking as a potential complication. This may not be identifiable intraoperatively due to lack of scroll formation.

Anatomical Changes in the Anterior Chamber Volume After Descemet Membrane Endothelial Keratoplasty.

PURPOSE: To evaluate changes in the anterior chamber of eyes that have undergone Descemet membrane endothelial keratoplasty (DMEK) and to identify factors that affect these changes. METHODS: This retrospective study included 25 pseudophakic eyes of 25 patients who underwent DMEK. We determined the preoperative and postoperative values of the best spectacle-corrected visual acuity, spherical equivalent (SE), anterior chamber volume (ACV), anterior chamber depth (ACD), central corneal thickness (CCT), and scleral spur angle (SSA) evaluated using anterior segment optical coherence tomography and iris damage score and iris posterior synechiae score. We defined ∆ as the average change rate from the preoperative to postoperative value for each factor at 1 month (SE at 6-12 months) postoperatively. We also analyzed correlations between ∆ACV, ∆SE, and other preexisting factors. RESULTS: Compared with the preoperative ACV value (128 ± 28 mm3), the postoperative value significantly increased to 155 ± 21 mm3 (P < 0.001); ∆SE was +1.01 ± 1.09 diopters. ∆ACV was negatively correlated with preoperative ACD (R = 0.643, P < 0.001) and SSA (R = 0.555, P = 0.001) and positively correlated with ∆ACD (R = 0.799, P < 0.001) and ∆SSA (R = 0.608, P < 0.001). ∆CCT, iris damage score, and iris posterior synechiae score were not significantly correlated with ∆ACV. ∆SE was positively correlated with ∆ACV, ∆ACD, and ∆SSA (R = 0.680, 0.455, and 0.478; P < 0.001, <0.05, and <0.05, respectively). CONCLUSIONS: An increase in the ACV and hyperopic change was noted after successful DMEK, especially in eyes with narrow-angled shallow anterior chambers.

Treatment strategy for primary lung cancer in a lung highly compressed by giant emphysematous bullae: A case report.

Lung cancer sometimes develops on the wall of a giant emphysematous bulla (GEB). Herein, we describe a rare case in which lung cancer developed in lung tissue compressed by GEBs. A 62-year-old man underwent a computed tomography (CT) scan that revealed two right GEBs. A tumor was suspected in the highly compressed right upper lobe. Since the right bronchus was significantly shifted toward the mediastinum, it was difficult to perform a bronchoscopy. We inserted thoracic drains into the GEBs, and a subsequent CT scan revealed re-expansion of the remaining right lung and a 3.3 cm tumor in the right upper lobe. The shift of the right bronchus was improved, and bronchoscopy was performed. The tumor was diagnosed as non-small cell lung cancer (NSCLC). Additionally, the GEBs were found to have originated from the right lower lobe. We performed a right upper lobectomy, mediastinal lymph node dissection, and bullectomy of the GEBs via video-assisted thoracoscopic surgery. In preoperative evaluation of a GEB, assessing re-expansion and lung lesions of the remaining lung is important, and intracavity drainage of a GEB may be useful. KEY POINTS: Significant findings of the study Cancer that develops in lung tissue highly compressed by a giant emphysematous bulla is difficult to diagnose. In the preoperative evaluation of a giant emphysematous bulla, assessing re-expansion and lung lesions of the remaining lung is important. What this study adds After performing intracavity drainage of a giant emphysematous bulla, the remaining lung re-expands, and the bronchial shift improves; subsequently, bronchoscopy makes it possible to diagnose lung cancer in the remaining lung.

Osteoporosis in Skin Diseases.

Osteoporosis (OP) is defined as a generalized skeletal disease characterized by low bone mass and an alteration of the microarchitecture that lead to an increase in bone fragility and, therefore, an increased risk of fractures. It must be considered today as a true public health problem and the most widespread metabolic bone disease that affects more than 200 million people worldwide. Under physiological conditions, there is a balance between bone formation and bone resorption necessary for skeletal homeostasis. In pathological situations, this balance is altered in favor of osteoclast (OC)-mediated bone resorption. During chronic inflammation, the balance between bone formation and bone resorption may be considerably affected, contributing to a net prevalence of osteoclastogenesis. Skin diseases are the fourth cause of human disease in the world, affecting approximately one third of the world's population with a prevalence in elderly men. Inflammation and the various associated cytokine patterns are the basis of both osteoporosis and most skin pathologies. Moreover, dermatological patients also undergo local or systemic treatments with glucocorticoids and immunosuppressants that could increase the risk of osteoporosis. Therefore, particular attention should be paid to bone health in these patients. The purpose of the present review is to take stock of the knowledge in this still quite unexplored field, despite the frequency of such conditions in clinical practice.

Secondary spontaneous pneumothorax and bullous lung disease in cannabis and tobacco smokers: A case-control study.

BACKGROUND: The notion that smoking cannabis may damage the respiratory tract has been introduced in recent years but there is still a paucity of studies on this subject. The aim of this study was to investigate the relationship between cannabis smoking, pneumothorax and bullous lung disease in a population of operated patients. METHODS AND FINDINGS: We performed a retrospective study on patients operated on for spontaneous pneumothorax. Patients were divided into three groups according to their smoking habit: cannabis smokers, only-tobacco smokers and nonsmokers. Cannabis lifetime exposure was expressed in dose-years (1d/y = 1 gram of cannabis/week for one year). Clinical, radiological and perioperative variables were collected. The variables were analyzed to find associations with smoking habit. The impact of the amount of cannabis consumption was also investigated by ROC curves analysis. Of 112 patients, 39 smoked cannabis, 23 smoked only tobacco and 50 were nonsmokers. Median cannabis consumption was 28 dose/years, median tobacco consumption was 6 pack/years. Cannabis smokers presented with more severe chronic respiratory symptoms and bullous lung disease and with a higher incidence of tension pneumothorax than both tobacco smokers and nonsmokers. Cannabis smokers also developed a larger pneumothorax, experienced prolonged postoperative stay and demonstrated a higher incidence of pneumothorax recurrence after the operation than nonsmokers did. The risk of occurrence of chronic respiratory symptoms and bullous lung disease in cannabis smokers was dose-related. CONCLUSIONS: Cannabis smoking seems to increase the risk of suffering from respiratory complaints and can have detrimental effects on lung parenchyma, in a dose-dependent manner. Cannabis smoking also negatively affected the outcome of patients operated for spontaneous pneumothorax. A history of cannabis abuse should always be taken in patients with pneumothorax. There may be need for a specific treatment for pneumothorax in cannabis smokers.

The effectiveness of colchicine combined with mitomycin C to prolong bleb function in trabeculectomy in rabbits.

PURPOSE: To investigate the potential of colchicine to improve bleb function after trabeculectomy. METHODS: To find the maximum usable colchicine concentration, an ocular irritation study was performed with the Draize test at concentrations of 0.001%, 0.01% and 0.1%. Additionally, the synergistic effect of topical colchicine instillation and MMC application to surgical site was evaluated in a rabbit model by measuring changes after trabeculectomy in intraocular pressure (IOP) and bleb morphology score at 3, 7, 14, 21, 28, 35, 42, and 49 days. RESULTS: Experiments with a rabbit model of trabeculectomy showed that 0.04% MMC plus 0.01% colchicine was more effective than saline and 0.04% MMC alone in maintaining IOP reduction at days 7-49 (P < 0.01 at all time points) and day 49 (P < 0.05), respectively, while 0.04% MMC alone was more effective than saline only at days 7-35 (P < 0.05 at all time points). 0.04% MMC plus 0.01% colchicine and 0.04% MMC alone were more effective than saline at preserving bleb score at days 7-21 and 35-49 (P < 0.05 at all time points) and at days 7-35 (P < 0.05 at all time points), respectively. CONCLUSION: Colchicine may be a promising adjuvant for strengthening the effect of MMC and improving the survival of the filtering bleb in trabeculectomy.

Epidermolysis Bullosa Patients' Perception of Surgical Wound and Scar Healing.

BACKGROUND: There is limited evidence to suggest patients with epidermolysis bullosa (EB) have more postoperative wound complications than the general population. Despite this, the authors have noted reluctance among some surgeons to operate on these patients. OBJECTIVE: A cross-sectional study was designed to investigate postoperative wound and scar healing outcomes in patients with EB. METHODS: Patients were asked to complete the "Surgical Wound and Scar Healing in EB" questionnaire, and data gathered were analyzed. RESULTS: Forty-six patients completed the questionnaire for a total of 94 different surgical procedures. Five patients reported blistering at the surgical wound site. All 5 had generalized forms of EB. Four patients reported wound infections, and 1 patient reported wound dehiscence. The postoperative scar healed with keloid or hypertrophic scarring after 26% of the reported surgical procedures. CONCLUSION: Blistering at the postoperative site seems to be uncommon and particularly unlikely to occur in localized forms of EB. Postoperative wound infections and dehiscence are uncommon. Patients with EB may have a propensity to develop keloid or hypertrophic scarring. With these data, the authors hope clinicians have greater confidence in referring patients with EB for surgery, and surgeons more reassured about postoperative wound healing.

Photo Rounds: Painful blisters on fingertips and toes.

Our patient had visited the emergency department for painful blisters on her fingertips and toes. A follow-up visit to our clinic unearthed the cause.

Longitudinal Changes in Bleb Height, Vascularity, and Conjunctival Microcysts After Trabeculectomy.

OBJECTIVE: The objective of this article was to study longitudinal changes in bleb morphology (presence of microcysts and bleb height and vascularity) in subjects enrolled in the Singapore 5-Fluorouracil (5-FU) trabeculectomy study. STUDY DESIGN: Retrospective subgroup analysis of a randomized controlled trial. MATERIALS AND METHODS: Following trabeculectomy with either 5-FU or placebo, subjects were reviewed at day 1, weeks 1, 2, and 3, and months 3, 6, 9, 12, 16, 20, 24, 28, 32, and 36 and intraocular pressure (IOP), presence of microcysts and bleb height and vascularity graded and recorded. Statistical analyses were used to investigate baseline factors (demographics, eye drops use, IOP, treatment type, and comorbidities) that might account for long-term bleb changes and assess the influence of bleb morphology on mean, maximum, minimum, and variation in IOP following trabeculectomy. RESULTS: One hundred fifty-nine (61.2%) subjects completed follow-up and 71 subjects (44.7%) received 5-FU. Proportion of subjects with microcysts increased posttrabeculectomy till weeks 3 and 6 in 5-FU and placebo-treated eyes, respectively, before decreasing. Presence of microcysts at day 1 and week 2 was associated with lower mean (P=0.027 to 0.033), maximum (P=0.040), and minimum IOP (P=0.010). Mean bleb height decreased over 36 months and at months 20 and 36 was associated with maximum (P=0.031) and minimum IOP (P=0.032), respectively. Mean bleb vascularity decreased till month 9 and remained fairly constant after. CONCLUSIONS: Microcysts seen early posttrabeculectomy is associated with lower IOP. Blebs reduce in height as they remodel and the relationship between bleb vascularity and IOP is complex.

Acute COPD exacerbation presenting with pronounced intrabullous haemorrhage and haemoptysis.

A 54-year-old man with history of chronic obstructive pulmonary disease (COPD) presented with subacute onset of chest pain, shortness of breath, productive cough with haemoptysis and night sweats. There were no fever or recent weight loss reported. The chest radiograph showed right upper lobe bullae with adjacent opacification and an emphysematous lung. Due to worsening haemoptysis and persistent chest pain, CT of the chest with contrast was performed, which revealed moderate to severe emphysema and numerous blood-filled bullae. Cardiac work-up for chest pain was negative for myocardial ischaemia and for aortic dissection. Further infectious work-ups for mycobacterial and invasive fungal infection were negative. The patient was treated for acute COPD exacerbation and responded well to the antibiotics with the resolution of haemoptysis. Follow-up CT of the chest revealed the gradual resolution of the haemorrhage, while the patient remained asymptomatic.