Donor Characteristics in Graft Detachment after Posterior Lamellar Keratoplasty for Fuchs Endothelial Dystrophy and Bullous Keratopathy.

Background: Descemet Membrane Endothelial Keratoplasty (DMEK) has been widely adopted to treat Fuchs endothelial dystrophy (FED) and Bullous keratopathy (BK). Graft detachment (GD) is one of the common earliest post-operatory complications, and it is usually recovered by Air Rebubbling (ARB). Methods: Retrospectively, we investigated predictive factors related to GD between January 2016 and March 2020, a pre-COVID era, in 72 patients, 72 eyes, and their donors' lamellar characteristics, focusing on donor's cause of death. The patients were divided according to the posterior lamellar keratoplasty technique adopted. Results: GD and consequent ARB were most common but not significantly prevalent in DMEK (p = 0.11). It was more common in FED for both surgical approaches. Only in BK treated with DSAEK were host steeper mean astigmatism (p = 0.03) and donors with smaller graft pre-cut diameters (p = 0.02) less likely to be related to GD. Regarding donor's cause of death, only cardiovascular accident could be related to GD in BK treated with DMEK (p = 0.04). Conclusions: Our study shows that the conventional match between pathology and corneal lenticule is not sufficient to prevent ARB. Donor's cause of death can impair graft and host attachment. In particular, cardiovascular death may impair the efficiency of donors' endothelial cells, inducing GD after DMEK in BK.

Confocal microscopy analysis of corneal changes after photorefractive keratectomy plus cross-linking for keratoconus: 4-year follow-up.

PURPOSE: To analyze corneal confocal microscopy changes after combined photorefractive keratectomy (PRK) plus the cross linking (CXL) procedure. DESIGN: Prospective interventional case series. METHODS: At the Department of Basic Medical Sciences, Neuroscience, and Sense Organs of the University of Bari, Bari, Italy, 17 eyes of 17 patients with progressive keratoconus underwent confocal microscopy examination before and after 1, 3, 6, 12, 18, and 48 months following PRK plus the CXL procedure. The main outcome measures were mean superficial epithelial cell density; mean basal epithelial cell density; mean anterior, mid and posterior keratocyte density; qualitative analysis of stromal backscatter; sub-basal and stromal nerve density parameters; and mean endothelial cell density. RESULTS: During the 4-year follow-up, the mean superficial epithelial cell density, mean basal epithelial cell density and mean endothelial cell density remained unchanged (P > 0.05). The anterior mid-stromal keratocyte density showed a significant decrease (P < 0.05) as compared with preoperative values, and the posterior stromal keratocyte density showed a significant increase at 1 and 3 months of follow-up. Sub-basal and stromal nerve density parameters were significantly decreased until postoperative month 6 (P < 0.05 at 1, 3, and 6 months) and then tended to increase up to preoperative values by the 18th postoperative month. CONCLUSION: Corneal changes after the PRK plus CXL procedures seem to be pronounced and long lasting as far as keratocyte density of the anterior and mid stroma is concerned. Sub-basal nerve densities tend to reach preoperative values 6 months after surgery.

Photorefractive keratectomy followed by cross-linking versus cross-linking alone for management of progressive keratoconus: two-year follow-up.

PURPOSE: To compare visual, refractive, topographic, and corneal higher-order aberration outcome at the 2-year follow-up after customized photorefractive keratectomy (PRK) followed by cross-linking (CXL) as a single procedure versus CXL alone in eyes with progressive keratoconus. DESIGN: Prospective, interventional, nonrandomized clinical trial. METHODS: Seventeen patients (34 eyes) with progressive keratoconus were assigned to 2 groups: the worse eye (17 eyes) was assigned to the PRK plus CXL group and the better eye (17 fellow eyes) was assigned to the CXL group. RESULTS: In the PRK plus CXL group, uncorrected distance acuity improved significantly, from a mean ± standard deviation of 0.63 ± 0.36 logarithm of the minimal angle of resolution (logMAR) units to 0.19 ± 0.17 logMAR units (P < .05) and best distance acuity from 0.06 ± 0.08 logMAR to 0.03 ± 0.06 logMAR (P < .05). Manifest refraction spherical equivalent and spherical and cylindrical power improved significantly (P < .05). Simulated keratometry, flattest, steepest, average, cylindrical, apex keratometry, and inferior-superior value decreased significantly (P < .05). Total and coma-like aberrations significantly decreased for all pupil diameters (P < .05). In the CXL group, uncorrected distance acuity improved, but not significantly, from 0.59 ± 0.29 logMAR units to 0.52 ± 0.29 logMAR units, and best distance acuity improved from 0.06 ± 0.11 logMAR units to 0.04 ± 0.07 logMAR units (P > .05). Manifest refraction spherical equivalent and cylindrical power improvement was not significant (P > .05), unlike spherical power (P < .05). Steepest simulated keratometry, average simulated keratometry, and inferior-superior value significantly decreased (P < .05), unlike flattest simulated keratometry, cylindrical simulated keratometry, and apex keratometry (P > .05). Total and coma-like aberrations were not decreased significantly for all pupil diameters (P > .05). No significant endothelial changes were observed in either group. CONCLUSIONS: The PRK plus CXL procedure may be a good option to reduce corneal aberrations and stabilize corneas with progressive keratoconus.

Combined aniridia ring implantation and cataract surgery in an Axenfeld-Rieger syndrome: a UBM report.

PURPOSE: To describe ultrasound biomicroscopy (UBM) features in a patient with Axenfeld-Rieger syndrome (ARS) and cataract before and after anterior segment surgery using intraocular lens (IOL) and aniridic ring implantation (Morcher Aniridia rings 50 D). METHODS: Visual acuity, subjective glare disability, intraocular pressure, endothelial cell density, and UBM imaging were reviewed over a period of 1 year. RESULTS: One month after surgery, the operated eye showed improved visual acuity and visual comfort, and UBM examination showed a well-centered IOL and well-aligned aniridic ring fins. After 8 months, UBM examination showed contraction of the capsular bag, which appeared wrinkled, fibrous, and thickened. The capsular bag comprised the aniridic ring fins, causing misalignment. The glare disability had dropped from grade 0 to 3. The same outcome was present at 1 year. CONCLUSION: Ultrasound biomicroscopy is a useful noninvasive diagnostic means to picture anatomic details before and after surgery; it suggested that capsular bag shrinking caused migration of the aniridic rings, 8 months after surgery.

Excimer laser-assisted lamellar keratoplasty and the corneal endothelium.

PURPOSE: To evaluate endothelial changes after excimer laser-assisted lamellar keratoplasty. DESIGN: Retrospective, interventional case series. METHODS: Seven eyes of 7 keratoconus patients were evaluated for 1 year after pachymetry-guided lamellar keratoplasty, performed using the iRES Laser (Ligi Tecnologie Medicali S.p.A.), with the Corneal Lamellar Ablation for Transplantation software (Ligi Tecnologie Medicali S.p.A.) procedure. Both anterior segment optical coherence tomography (Visante OCT; Carl Zeiss Meditec, Inc) and in vivo confocal microscopy (Corneal Confocal Microscope CS4; NIDEK Technologies) images were collected. RESULTS: Changes in morphologic features were investigated and the endothelium was assessed quantitatively in all 7 patients. In 6 eyes, we measured a mean residual bed thickness of 151.3 +/- 5.46 microm, and a mean endothelial cell density loss of 5.38% at 1 year after surgery, as compared with preoperative values. The mean percentage hexagonality change was 15.67%, and the mean coefficient of variation change was -21.11%. In 1 eye, a residual bed thickness of 72 microm was found and endothelial loss after 1 year was 72.26%; assessment of the coefficient of variation and percentage hexagonality by manual Confoscan4 software (NIDEK Technologies) was not practicable in this case. CONCLUSIONS: Our results showed that the Corneal Lamellar Ablation for Transplantation procedure induced mild changes to the endothelium in corneas with a mean residual bed thickness of 151.3 +/- 5.46 microm, but serious damage in one eye with a residual bed thickness of 72 microm.

A case of descemet's membrane rupture in a patient affected by Acanthamoeba Keratitis.

OBJECTIVES: We report ultrasound biomicroscopy (UBM) evidence of Descemet's membrane rupture in a patient affected by Acanthamoeba keratitis without corneal perforation. METHODS: A 38-year-old woman who was a habitual wearer of monthly disposable soft contact lens was admitted to our unit for a severe ulcerated corneal abscess. Two days after admission, the patient presented acute stromal hydrops. Ultrasound biomicroscopy examination revealed a Descemet's membrane rupture and an inflammatory reaction in the anterior chamber. Smears with Gram 17 staining and cultural examination revealed the presence of Acanthamoeba. We started specific therapy with propamidine 0.1% and polyhexamethylene biguanide 0.02% eyedrops; we suspended propamidine therapy after 2 weeks form the onset, when the ulcer had recovered, and we continued topical therapy with polyhexamethylene biguanide 0.02% for 6 months. We performed UBM examinations at each control visit during the follow-up that lasted for 18 months. RESULTS: At 1-month's follow-up, the symptoms and corneal alterations had significantly improved, while UBM revealed a spontaneous reattachment of the endothelium-Descemet layer. At 12 months' follow-up, best-corrected visual acuity had improved from hand movements at onset to 20/40, and no sign of intraocular involvement was evidenced. CONCLUSIONS: Acanthamoeba is a ubiquitous protozoan that can affect the cornea, even colonizing the deep layers, causing rupture of the Descemet's membrane. Ultrasound biomicroscopy examination confirmed the severe pathogenicity of this parasite and confirmed that only a prompt diagnosis can limit the damage caused by this affection.

Capsular block syndrome after implantation of an accommodating intraocular lens.

A patient presented with capsular block syndrome (CBS) 1 month after cataract surgery. An unexpected postoperative myopia linked to shallowing of the anterior chamber was evident. The 1540 microm IOL shift was sufficient to give useful spectacle-free near vision. A neodymium:YAG laser peripheral anterior capsulotomy enabled the intracapsular liquid to flow into the anterior chamber, allowing normal placement of a 1CU IOL (HumanOptics AG) but revealing the limited accommodative ability of the IOL to cover the dioptric range from reading distance to infinity. The visual outcome of the patient is in accord with that in other studies of the effective of IOL shifting.

Topographic customized photorefractive keratectomy for regular and irregular astigmatism after penetrating keratoplasty using the LIGI CIPTA/LaserSight platform.

PURPOSE: To evaluate the use of a software ablation program (Corneal Interactive Programmed Topographic Ablation [CIPTA]) that provides customized photorefractive keratectomy (PRK) to correct astigmatism after keratoplasty. METHODS: In this prospective, noncomparative, consecutive case series, 44 eyes underwent CIPTA for correction of astigmatism after penetrating keratoplasty. Eighteen eyes were treated for regular astigmatism and 26 eyes were treated for irregular astigmatism after penetrating keratoplasty. Orbscan II topography (Bausch & Lomb) and a flying-spot laser (LaserScan 2000; LaserSight) were used. Epithelial debridement with alcohol was performed before PRK in 16 eyes and transepithelial PRK was performed in 28 eyes. Mean target-induced astigmatism was 8.19 +/- 2.68 diopters (D) and 7.68 +/- 4.50 D in the regular and irregular astigmatism groups, respectively. RESULTS: Mean follow-up was 25.4 +/- 13 months. At last postoperative follow-up, 13 (72.2%) and 18 (69.2%) eyes in the regular and irregular astigmatism groups, respectively, had uncorrected visual acuity (UCVA) better than 20/40. Four (22.2%) and 8 (30.7%) eyes in the regular and irregular astigmatism groups, respectively, had UCVA of 20/20. Fourteen (77.7%) and 18 (69.2%) eyes in the regular and irregular astigmatism groups, respectively, were within 1.00 D of attempted correction in spherical equivalent manifest refraction. No eye lost Snellen lines of best spectacle-corrected visual acuity. Mean surgically induced astigmatism was 7.66 +/- 2.70 D and 6.99 +/- 3.80 D for the regular and irregular astigmatism groups, respectively. Index of success of astigmatic correction was 0.138 and 0.137 for the regular and irregular astigmatism groups, respectively. Haze developed in three eyes. CONCLUSIONS: Topography-driven PRK using CIPTA software is a suitable solution for correcting regular and irregular astigmatism after penetrating keratoplasty.

Combined topical anesthesia and sedation for open-globe injuries in selected patients.

PURPOSE: To evaluate the efficacy and safety of topical anesthesia (TA) and IV sedation in surgery for less severe open-globe injury (OGI). DESIGN: Noncomparative consecutive interventional case series. PARTICIPANTS: Of 67 OGI cases reviewed at the Department of Ophthalmology and Otolaryngology, University of Bari, Bari, Italy, in the period from 1999 to 2000, 10 eyes (14.9%) of 10 consecutive patients (age range, 6-58 years) were repaired using TA and IV sedation. All patients belonged to the American Society of Anesthesiologists risk class I or II. Nine eyes had corneoscleral wounds, four had vitreous loss, two had traumatic cataract, and three had an intraocular foreign body (IOFB); one patient had interruption of a continuous penetrating keratoplasty suture. Preoperatively, best-corrected visual acuity (BCVA) ranged from hand movement to 20/20. INTERVENTION: Corneoscleral suture was performed in nine patients, vitreous excision in four, uveal excision or reposition in four, IOFB removal in three, and cataract extraction in two; corneal button resuture was carried out in one patient. All patients received topical oxybuprocaine hydrochloride 0.4%, and IV propofol, midazolam, and fentanyl for anesthesia. MAIN OUTCOME MEASURES: The change in BCVA was evaluated. Within 24 hours after surgery, each patient was asked to grade subjective pain and discomfort on a 4-point scale. The surgeon was asked to report difficulties attributable to the operating conditions. Complications related to anesthesia and to surgery were assessed. RESULTS: Best-corrected visual acuity stabilized or improved in all patients. All patients had grade 1 pain and discomfort during most of the procedure. All patients had grade 2 (mild) pain and discomfort during external bipolar cautery and conjunctival closure. No patient required additional anesthesia. The operating conditions as reported by the surgeons were graded slightly difficult in all cases but one, which was graded moderately difficult. No patient had surgical or anesthesia-related adverse events or life-threatening complications. CONCLUSIONS: Topical anesthesia and IV sedation are safe and effective and could be a reasonable alternative for less severe OGI. The degree of patient discomfort is only marginal during surgery and postoperatively. However, surgical training and patient preparation are the keys to the safe use of this anesthetic modality.

Accuracy of Orbscan optical pachymetry in corneas with haze.

PURPOSE: To compare corneal thickness measurements with the Orbscan instrument (Orbtek, Inc.) and an ultrasonic pachymeter (Alcon Surgical) in corneas with haze. SETTING: Department of Ophthalmology and Otolaryngology, University of Bari, Bari, Italy. METHODS: Six eyes of 6 patients having phototherapeutic keratectomy for treatment of grade 2+ haze were assessed preoperatively and postoperatively by Orbscan optical pachymetry and ultrasonic pachymetry. Contralateral transparent untreated corneas of the same patients were used as controls. Two Orbscan and 5 ultrasound pachymetry measurements were performed at each visit and the mean values recorded. The accuracy and repeatability of the measurements were evaluated. RESULTS: Preoperatively, the median corneal thickness in the 6 eyes with haze was 512.7 microm by ultrasonic pachymetry and 375.0 microm by optical pachymetry. The mean difference of 143.1 microm was statistically significant (Wilcoxon signed rank test, P= .0277). Postoperatively, the median pachymetry was 439.0 microm and 433.0 microm, respectively; the mean difference was 10.7 microm (P= .0277). In the control group, the median ultrasonic pachymetry was 530.9 microm and the median optical pachymetry, 529.0 microm; the mean difference was 4.7 microm (P= .1730). Precision was good in all groups; the standard deviation was less than 6.0 microm. CONCLUSIONS: The Orbscan system showed a decreased accuracy in measuring corneal thickness when clinically significant haze was present. The repeatability of the measures was good, suggesting that the cause of error lies in the optical acquisition process.