Trends in corneal transplant surgery in Ireland: indications and outcomes of corneal transplant surgery and intraocular lens opacification following Descemet's stripping automated endothelial keratoplasty.

PURPOSE: To evaluate the indications for corneal transplantation, the procedures carried out, and the postoperative outcomes and to compare these with previous Irish corneal transplant studies. METHODS: A retrospective review of the case notes of all patients who underwent corneal transplantation under the care of a single surgeon, from 2008 to 2015, was performed. The risk factors for postoperative complications including transplant failure were examined. RESULTS: During the period studied, 42 corneal transplant surgeries were carried out on 40 eyes of 38 patients, 24 of whom were male (63%), median age at surgery was 62 years (range 23-96 years). The most common indication for transplantation was pseudophakic corneal decompensation associated with Fuch's endothelial dystrophy (FED) (n = 13). Seventeen penetrating keratoplasties, 23 lamellar keratoplasties, and two amniotic membrane transplant procedures were carried out. Transplant failure resulting in corneal oedema or repeat corneal transplant surgery (n = 4, 10%), was associated with previous transplant failure in the eye; odds ratio (OR) = 1.58 (p = 0.05), and with comorbid FED, OR = 1.50 (p = 0.02). Intraocular lens opacification occurred in one lens following DSAEK, giving an incidence rate of 7%. CONCLUSIONS: Pseudophakic corneal decompensation is the commonest indication for corneal transplant surgery, with lamellar keratoplasty the most frequent approach in our cohort, reflecting developments observed in corneal transplant surgery elsewhere. Prior corneal transplant failure and Fuch's dystrophy remain important risk factors for failure. The risk of intraocular lens opacification and its potential effects on vision should be elaborated prior to endothelial keratoplasty.

Mesenchymal stem cell therapy promotes corneal allograft survival in rats by local and systemic immunomodulation.

Mesenchymal stem cells (MSCs) are being investigated extensively due to their ability to dampen immune responses. Here, we tested the ability of MSCs from three distinct sources to prolong rat corneal allograft survival. A fully allogeneic rat cornea transplant model (DA to LEW) was used. Recipient rats received 1 × 10(6) MSCs (syn [LEW], allo [DA] or third-party [Wistar Furth]) intravenously 7 days before transplantation and again on the day of transplantation (day 0). A high percentage of untreated and syn-MSC treated allografts were rejected (80% and 100%, respectively). Preactivation of syn-MSCs with interferon gamma also failed to prolong allograft survival. Conversely, corneal allograft survival was significantly prolonged in allo-MSC treated (90%) and third-party MSC treated (80%) allograft recipients. Flow cytometric analysis revealed less infiltrating natural killer T cells in corneas of both allo- and third-party MSC treated animals, coupled with a higher proportion of splenic CD4+Foxp3+ regulatory T cells, compared to controls. In the case of allo- and third-party MSCs, results from a delayed-type hypersensitivity assay clearly showed that hypo-responsiveness was specific for corneal donor-associated allo-antigens. Thus, allo- and third-party MSC treatment prolongs corneal allograft survival by suppressing peripheral immune responses and promoting an intragraft immunoregulatory milieu.

Horizontal strabismus surgical outcomes in a teaching hospital.

Strabismus may result in impaired stereopsis, diplopia, undesirable appearance, amblyopia and negative psychological impact. This study provides epidemiological and surgical outcome information about patients attending University College Hospital Galway requiring strabismus surgery. We report a retrospective analysis of 75 consecutive patients, who underwent horizontal strabismus surgery. Sixty-one (81.3%) patients had clinically significant refractive errors, hyperopia being the most common. Thirty-four (45.3%) patients had amblyopia and nine (12%) required further treatment. A cosmetically acceptable result with a post-operative ocular deviation within 25 prism dioptres of straight (grade 2) was achieved in 70/75 (93.3%) of patients. The overall mean change in ocular deviation per mm of muscle operated was 3.25 prism dioptre/mm. The outcomes of strabismus surgery in an Irish hospital compare very favourably with other jurisdictions. This data will help plan service delivery.

The profile of patients attending a triaged eye emergency service.

BACKGROUND: Galway University Hospital provides a 24-h referral eye emergency service for patients triaged by a primary health network. AIMS: A prospective study was designed to evaluate the profile of patients referred to the eye emergency service and an attempt was made to compare the data recorded to those of a walk-in eye casualty. METHODS: All cases seen in Galway University Hospital eye emergency service over five consecutive weeks in 2012 were recorded and analyzed. RESULTS: Four hundred and eight cases were seen in total. 312 (76.5 %) were seen during normal working hours and 96 (23.5 %) after-hours. 33.3 % of cases were inflammatory and 31.9 % traumatic. Anterior uveitis [39 cases (9.6 %)] and corneal abrasion [37 cases (9.1 %)] were the most common diagnosis, while bacterial keratitis [9 cases (2.2 %)] and globe rupture/penetration [4 cases (1 %)] were the most serious. 85.6 % of patients were seen within 30 h from referral. A&E department was the main referral source (35 % of cases seen during normal hours and 70.8 % of those seen after-hours). 42.5 % of patients needed to be followed-up in the clinics. Seventy-two patients (17.6 %) were seen after 5 pm, Monday to Monday. Twenty-one were traumatic, 4 required admission and only 9 were deemed inappropriate after assessment. CONCLUSIONS: Serious eye pathology presents after normal working hours. The triage process results in lower number of minor complaints being referred to the service. Compared to a walk-in casualty, a triaged service manages greater percentage of complex pathology.

Morphological and functional preservation of pre-antral follicles after vitrification of macaque ovarian tissue in a closed system.

STUDY QUESTION: What are the appropriate conditions to vitrify the macaque ovarian cortex in a large-volume, closed system that will preserve functional pre-antral follicles? SUMMARY ANSWER: The combination of glycerol, ethylene glycol (EG) and polymers with cooling in liquid nitrogen (LN2) vapor and a two-step warming procedure was able to preserve tissue and follicle morphology as well as function of a small population of secondary follicles in the macaque ovarian cortex following vitrification in a closed system. WHAT IS KNOWN ALREADY: For prepubertal cancer patients or those who require immediate cancer therapy, ovarian tissue cryopreservation offers the only hope for future fertility. However, the efficacy of live birth from the transplantation of cryopreserved ovarian tissue is still unclear. In addition, live birth from cryopreserved ovarian tissue has only been demonstrated after tissue autotransplantation, which poses the risk of transmitting metastatic cancer cells back to the cancer survivor in certain cancers. STUDY DESIGN, SIZE, DURATION: Non-human primate model, n = 4, randomized, control versus treatment. End-points were collected from tissue histology, tissue culture (48 h) and isolated secondary follicle culture (6 weeks). PARTICIPANTS/MATERIALS, SETTING, METHODS: Two vitrification solutions (VSs) containing EG + glycerol (VEG) and EG + dimethylsulfoxide (VED) were examined for vitrification, devitrification and thermodynamic properties. Once the optimal VS was determined, macaque ovarian cortical pieces (3 × 3 × 0.5 mm(3)) were divided into fresh and two vitrified groups (VEG and VED). For the vitrification groups, tissues were exposed to 1/4, 1/2 and 1× VS for 5 min/step as well as 1× VS + polymers for 1 min at 37°C, loaded into high-security straws with 1 ml of VS + polymers, heat sealed and cooled in LN2 vapor. Samples were warmed in a 40°C water bath and cryoprotective agents were diluted with 1, 0.5, 0.25 and 0 M sucrose. Tissues were fixed for histological analysis and cultured with bromodeoxyuridine (BrdU). Secondary follicles from VEG tissues were encapsulated and cultured (n = 24/treatment/animal). Follicle health, diameter and steroid [progesterone, androstenedione (A4), estradiol (E2)] production were analyzed weekly. MAIN RESULTS AND THE ROLE OF CHANCE: Dense stroma and intact pre-antral follicles were observed using VS containing 27% glycerol, 27% EG and 0.8% polymers with cooling in LN2 vapor and a two-step warming. Higher cooling and warming rates led to fracturing. BrdU uptake was evident in granulosa cells of growing follicles in fresh and vitrified tissues. Secondary follicles from fresh tissues (70 ± 12%) and tissues vitrified with VEG (52 ± 2%) showed similar survival rates (all data: mean ± SEM; P > 0.05). For both groups, the initial follicle diameter was similar and increased (P < 0.05) by Week 3, but diameters in vitrified follicles were smaller (P < 0.05) by Week 6 (566 ± 27 µm) than those of the fresh follicles (757 ± 26 µm). Antrum formation rates were lower (P < 0.05) for vitrified (37 ± 6%) relative to fresh (64 ± 8%) follicles. There was no significant change in levels in culture media of E2, P4 and A4 between fresh and VEG groups at any time point during culture. LIMITATIONS, REASONS FOR CAUTION: Only in vitro studies are reported. Future in vivo tissue transplantation studies will be needed to confirm long-term function and fertility potential of vitrified ovarian tissues. WIDER IMPLICATIONS OF THE FINDINGS: This is the first demonstration of antral follicle development during 3D culture following ovarian tissue vitrification in a closed system using primate ovarian tissue. While diminished antrum formation and slower growth in vitro reflect residual cryodamage, continued development of ovarian tissue vitrification based on cryobiology principles using a non-human primate model will identify safe, practical and efficient protocols for eventual clinical use. Tissue function following heterotopic transplantation is currently being examined. STUDY FUNDING/COMPETING INTEREST(S): National Institutes of Health (NIH) Oncofertility Consortium UL1 RR024926 (1RL1-HD058293, HD058295, PL1 EB008542), the Eunice Kennedy Shriver NICHD/NIH (U54 HD018185) and ONPRC 8P51OD011092-53. G.M.F. works for the company that makes the polymers used in the current study.

A chronologic review of mature oocyte vitrification research in cattle, pigs, and sheep.

Vitrification as a means of cryopreservation has become a standard approach for oocytes from livestock. This paradigm shift occurred primarily as a result of the demonstration in 1996 that bovine oocytes are extremely susceptible to chilling injury. Since that early work, numerous devices have been used as supports for oocytes during so-called "ultra-rapid cooling", and occasionally, trials involving the deposition of small volumes of media containing oocytes directly into liquid nitrogen to facilitate cooling have been reported. Results reporting blastocyst development exceeding 10% are common, but variability remains high, and a standard method for bovine oocytes remains to be established. Oocytes from pigs are particularly difficult to cryopreserve, even with the use of ultrarapid cooling approaches. Few reports have demonstrated blastocyst development exceeding 5%. The application of hydrostatic pressure before vitrification appears to impart stress tolerance to porcine oocytes, as the results of some treatments have shown development to blastocysts at proportions >10%. Work on sheep oocyte vitrification is relatively new, and a few articles have reported blastocyst development at 10% or more. Messenger RNA levels are reportedly altered in sheep oocytes as a result of vitrification, and damage to the cytoskeleton is common across species.

Deep supercooling, vitrification and limited survival to -100{degrees}C in the Alaskan beetle Cucujus clavipes puniceus (Coleoptera: Cucujidae) larvae.

Larvae of the freeze-avoiding beetle Cucujus clavipes puniceus (Coleoptera: Cucujidae) in Alaska have mean supercooling points in winter of -35 to -42 degrees C, with the lowest supercooling point recorded for an individual of -58 degrees C. We previously noted that some larvae did not freeze when cooled to -80 degrees C, and we speculated that these larvae vitrified. Here we present evidence through differential scanning calorimetry that C. c. puniceus larvae transition into a glass-like state at temperatures<-58 degrees C and can avoid freezing to at least -150 degrees C. This novel finding adds vitrification to the list of insect overwintering strategies. While overwintering beneath the bark of fallen trees, C. c. puniceus larvae may experience low ambient temperatures of around -40 degrees C (and lower) when microhabitat is un-insulated because of low snow cover. Decreasing temperatures in winter are correlated with loss of body water from summer high levels near 2.0 to winter lows near 0.4 mg mg(-1) dry mass and concomitant increases in glycerol concentrations (4-6 mol l(-1)) and thermal hysteresis. Finally, we provide direct evidence that Cucujus from Wiseman, Alaska, survive temperatures to -100 degrees C.

Coral larvae conservation: physiology and reproduction.

Coral species throughout the world's oceans are facing severe environmental pressures. We are interested in conserving coral larvae by means of cryopreservation, but little is known about their cellular physiology or cryobiology. These experiments examined cryoprotectant toxicity, dry weight, water and cryoprotectant permeability using cold and radiolabeled glycerol, spontaneous ice nucleation temperatures, chilling sensitivity, and settlement of coral larvae. Our two test species of coral larvae, Pocillopora damicornis (lace coral), and Fungia scutaria (mushroom coral) demonstrated a wide tolerance to cryoprotectants. Computer-aided morphometry determined that F. scutaria larvae were smaller than P. damicornis larvae. The average dry weight for P. damicornis was 24.5%, while that for F. scutaria was 17%, yielding osmotically inactive volumes (V(b)) of 0.22 and 0.15, respectively. The larvae from both species demonstrated radiolabeled glycerol uptake over time, suggesting they were permeable to the glycerol. Parameter fitting of the F. scutaria larvae data yielded a water permeability 2 microm/min/atm and a cryoprotectant permeability = 2.3 x 10(-4) cm/min while modeling indicated that glycerol reached 90% of final concentration in the larvae within 25 min. The spontaneous ice nucleation temperature for F. scutaria larvae in filtered seawater was -37.8+/-1.4 degrees C. However, when F. scutaria larvae were chilled from room temperature to -11 degrees C at various rates, they exhibited 100% mortality. When instantly cooled from room temperature to test temperatures, they showed damage below 10 degrees C. These data suggest that they are sensitive to both the rate of chilling and the absolute temperature, and indicate that vitrification may be the only means to successfully cryopreserve these organisms. Without prior cryopreservation, both species of coral settled under laboratory conditions.

Rapid cardioversion of new onset atrial fibrillation with ibutilide in the emergency department.

People with atrial fibrillation commonly present to the emergency department. Ibutilide is an anti arrhythmic indicated for the cardioversion of atrial fibrillation and flutter where the onset is less than 48 hours.

Prosthetic valve endocarditis caused by Veillonella parvula.

Veillonella species is a rare cause of endocarditis. We report a case of a 49-year-old man with Veillonella parvula prosthetic valve endocarditis who presented with acute cardiac failure due to valvular dehiscence. His clinical course was complicated by cortical blindness and limb paresis as a result of cerebral embolism. The endocarditis was successfully treated with urgent valve replacement surgery and a prolonged course of metronidazole.

Normothermic blood perfusion of isolated rabbit kidneys. II. In vitro evaluation of renal function followed by orthotopic transplantation.

This study describes the use of a blood perfusion apparatus to assess the renal function of isolated kidneys. Eight fresh kidneys were obtained from healthy rabbits and perfused with blood at 36 degrees C for 2 hours. Rabbit blood was drawn and diluted to a hematocrit of 25%. The kidneys were evaluated for their capacity to support life in an autograft model. Blood and urine samples were taken at regular time intervals during kidney perfusion. Serum creatinine was measured in surviving rabbits after transplantation. Over the course of the perfusion, arterial pressure was maintained at 87.2 +/- 5.5 mm Hg. The renal blood flow (3.7 +/- 1.0 ml/min per g) and urine output (0.11 +/- 0.04 ml/min per g) were continuously monitored. Glomerular filtration rate (0.29 +/- 0.02 ml/min per g) and fractional reabsorption (FR) of sodium and glucose indicated appreciable tubular function (FR(Na) = 67.9 +/- 8.5%, FR(Glu) = 91.2 +/- 5.8%). Protein was excluded from urine at 99.8% +/- 0.1%. After transplantation, the peak creatinine was 6.8 +/- 3.2 mg/dl at 1.90 +/- 0.92 days for the seven surviving rabbits and was above 16 mg/dl for the only rabbit that died 4 days after operation. The level of free hemoglobin generated at the end of the perfusion (2.6% +/- 2.8%) was correlated with the postoperative peak creatinine (r2 = 0.84). Perfusion of seven additional kidneys by using the roller pump lead to a final hemolysis of only 0.34 +/- 0.14%. Kidneys transplanted after 2 hours of blood perfusion were able to resume normal function and support life. Hemolysis was a measurable stress factor causing delayed function of the kidney after transplantation. Introduction of a roller pump significantly reduced the hemolysis.

Permanent life support by kidneys perfused with a vitrifiable (7.5 molar) cryoprotectant solution.

BACKGROUND: Vitrification (glass formation) is a potential method for indefinite term organ preservation that eliminates all of the conventional problems of freezing and thawing. A 7.5 M mixture of cryoprotectants known as VS4 is sufficiently concentrated, in combination with applied pressure, to preclude ice formation entirely during cooling to below the glass transition temperature (about -125 degrees C), at which point vitrification takes place, arresting further changes over time. METHODS: Rabbit kidneys were perfused with VS4 according to three different protocols. The kidneys were evaluated using an autograft model with immediate contralateral nephrectomy. RESULTS: All three methods permitted long-term survival, but the best results were obtained when the highest concentrations were perfused at about -3 degrees C. Using the latter protocol, the survival rate was 10/10, serum creatinine returned to a normal baseline after transient elevation, other clinical chemistry results normalized, and no histological damage was apparent 3 weeks after autografting. CONCLUSIONS: The results described provide the strongest evidence to date that it may be possible to bank kidneys for unlimited periods in the absence of ice for later transplantation.

Vitrification enhancement by synthetic ice blocking agents.

Small concentrations of the synthetic polymer polyvinyl alcohol (PVA) were found to inhibit formation of ice in water/cryoprotectant solutions. Ice inhibition improved with decreasing molecular weight. A PVA copolymer of molecular weight 2 kDa consisting of 20% vinyl acetate was found to be particularly effective. PVA copolymer concentrations of 0.001, 0.01, 0.1, and 1% w/w decreased the concentration of glycerol required to vitrify in a 10-ml volume by 1, 3, 4, and 5% w/w, respectively. Dimethyl sulfoxide concentrations required for vitrification were also reduced by 1, 2, 2, and 3% w/w, respectively. Crystallization of ice on borosilicate glass in contact with cryoprotectant solutions was inhibited by only 1 ppm of PVA copolymer. Devitrification of ethylene glycol solutions was also strongly inhibited by PVA copolymer. Visual observation and differential scanning calorimeter data suggest that PVA blocks ice primarily by inhibition of heterogeneous nucleation. PVA thus appears to preferentially bind and inactivate heterogeneous nucleators and/or nascent ice crystals in a manner similar to that of natural antifreeze proteins found in cold-hardy fish and insects. Synthetic PVA-derived ice blocking agents can be produced much less expensively than antifreeze proteins, offering new opportunities for improving cryopreservation by vitrification.