[Keratoplasty in the management of Terrien's marginal degeneration].

OBJECTIVE: To evaluate the efficacy and safety of keratoplasty combined with corneal foci resection in the treatment of Terrien's marginal degeneration (TMD). METHODS: In this nonrandomized retrospective case series, the records of 48 eyes from 40 patients with TMD who received keratoplasty from January 1995 to December 2005 in Zhongshan Ophthalmic Center were reviewed retrospectively. Orbscan topography examination was undertaken in 8 eyes of 8 patients and the refractive error of 9 eyes from 9 patients was tested before and after the operation. RESULTS: The mean age of the patients was (30 +/- 6) years old. The mean follow up period was (7 +/- 6) years. It took (3 +/- 1) months postoperatively to obtain a stable visual acuity. Before operation, the naked eye and best corrected visual acuity (VA) (Q25,Q75) were (0.05,0.4), and (0.1,0.5), respectively, while improved to (0.2,0.6) and (0.4,0.7) after operation, respectively (Z = 4.63, 3.85, both P<0.01). VA was improved in 39 eyes (81.3%), remained at the same level in 4 eyes (8.3%), decreased 1-2 lines in 3 eyes (6.3%), and decreased more than 2 lines in 2 eyes (4.1%) after the operation. The median spherical diopter and cylinder diopter were (-2.00 D, -8.50 D) and (2.50 D,12.00 D) before operation, while decreased to ( -1.25 D, -4.75 D) and (0.75 D, 4.25 D) after operation (Z= 2. 49, 2.54, P = 0.01, 0.01). The improvement in Sim K's astigmatism, astigmatism in 3 mm zone and mean power in 3 mm and 5 mm zone were reduced statistically significant after the operation (P <0.05); with the exception of astigmatism in the 5 mm zone, which was not reduced significantly after the operation (Z = 1.86, P = 0.06) . The operative complications included corneal perforation during operation in 5 eyes (10.4%), hydrops between graft and recipient interface in 8 eyes (16.7%), epithelial in-growth in 4 eyes (8.3%), choroidal detachment in 1 eye (2.1%), graft rejection in 7 eyes (14.6%), and recurrence in 3 eyes (6.3%). Secondary surgery was required in 5 eyes (10.4%) for interface hydrops, epithelial in-growth and recurrence of TMD. CONCLUSIONS: Keratoplasty combined with foci resection is effective and safe in the treatment of TMD. This procedure can preserve and improve the visual activity.

[Fresh versus preserved amniotic membrane transplantation for conjunctival surface reconstruction].

PURPOSE: To compare the effect of fresh versus preserved amniotic membrane transplantation for conjunctival surface reconstruction after symblepharon lysis and analyze the associated factors. METHODS: Fifty-one consecutive cases (55 eyes) with symblepharon at different degree due to eye burns or Stevens-Johnson syndrome were accepted lysis of symblepharon and amniotic membrane transplantation. Twenty-two eyes of them were performed with fresh amnion grafts, the others (33 eyes) with preserved human amniotic membrane. Eleven eyes were performed within 1 year and forty eyes in 1 to 8 years (mean value, 2.0 +/- 0.7 years) after eye burns. RESULTS: The follow-up time varied from 12 to 32 months (mean value, 19.3 +/- 4.1 months). Fifty-six point four percent (31/55) eyes got enough deep conjunctival fornix and resolution of eye movement restrict. Sixteen percent of them (9/55) recurred less symblepharon and remained slightly eye movement restrict. Fifteen-five eyes of them (27.3%) recurred moderate symblepharon. The effects of surgery were similar between fresh and preserved AMT (chi2 = 0.466, P = 0.797). The effects of AMT for those patients with symblepharon at different degree had significant difference statistically (fresh amnions, chi2 = 27.995, P = 0.000; preserved amnions, chi2 = 33.610, P = 0.000). The same results were observed between those patients who were performed in different time periods after eye burns (chi2 = 4.243, P = 0.039). CONCLUSION: Fresh amnion has the same effect as preserved one for conjunctival surface reconstruction. The degree of symblepharon and the surgical environment of the ocular surface in the affected eye before surgery will influence the results of amniotic membrane transplantation for conjunctival surface reconstruction.

[Preliminary clinical study of sutureless, small-incision deep lamellar endothelial keratoplasty surgery].

OBJECTIVE: To investigate the surgical procedure, clinical efficacy, and the prevention and management of complications of sutureless, small-incision deep lamellar endothelial keratoplasty (DLEK). METHODS: Nine patients (nine eyes) with bullous keratopathy underwent sutureless, small-incision DLEK surgery, six of them was combined with anterior vitrectomy. Visual acuity, graft clearance, corneal curvature, astigmatism and endothelial cell density (ECD) were observed over a 3 - 5 month follow-up period. RESULTS: All grafts remained transparent, and six eyes had improved visual acuity. After the surgery, mean corneal curvature was (43.96 +/- 3.38) D. Mean corneal astigmatism was (3.32 +/- 1.20) diopter (D). Mean ECD was (2124 +/- 278) cells/mm(2). No severe complications occurred. CONCLUSION: Sutureless, small-incision DLEK, as compared with penetrating keratoplasty (PKP) and microkeratome-associated deep lamellar endothelial keratoplasty, has more advantages and is expected to be the initial surgical treatment for bullous keratopathy.

[Clinical observation of wound dehiscence after penetrating keratoplasty].

OBJECTIVE: To investigate the treatment of wound dehiscence after penetrating keratoplasty and to evaluate the influence of this complication on visual outcome. METHODS: A retrospective analysis of 32 patients with wound dehiscence that undergone penetrating keratoplasty in Zhongshan Ophthalmic Center from July 1997 to June 2003 was performed. All involved eyes were undergone wound repair with or without iris excision, lensectomy, intraocular lens removal, anterior vitrectomy and stage I or stage II pars plana vitrectomy with gas or silicone oil tamponade according to variable extents of host-graft wound dehiscence in individual patient. Visual outcome, transparency of graft, intraocular pressure and structure integrity of ocular posterior segment were followed-up for 6-18 months in details. These data were used to summarize the specific characteristics of this type of ocular trauma. RESULTS: Surgical outcomes were recorded as the following: 24 eyeballs were rescued, but eight of them developed phthisis bulbi. Broken or loose sutures of eyes were found in eight cases. Six cases achieved better visual acuity, all of which maintained clear grafts with normal intraocular pressure, and no vitreous hemorrhage or choroidal/retinal detachment occurred. In 14 eyes with wound dehiscence of 1/4-1/2 circle, eight cases ended with decreased visual acuity, 11 with grafts opacities, five with abnormal intraocular pressure (above or below the normal range). In eight eyes with wound dehiscence of 1/2-3/4 circle, seven cases got decreased visual acuity, five with graft opacities, seven with abnormal intraocular pressure, four with vitreous hemorrhage, and four developing choroidal/retinal detachment. In the two eyes with wound dehiscence over 3/4 circle, both resulted in graft opacities with no light perception. Vitreous hemorrhage, choroidal/retinal detachment as well as phthisis bulbi occurred due to low intraocular pressure. CONCLUSIONS: After penetrating keratoplasty, the wounds of corneal graft show tectonic instability and poor resistance to tension. Traumatic wound dehiscence after penetrating keratoplasty often complicate with intraocular content herniation, vitreous hemorrhage, and choroidal/retinal detachment. Usually, this kind of trauma is from severe injuries and prognosis is worse than the common ocular trauma.

[Management of corneo-conjunctival malignant melanoma with "no touch technique" surgical excision and corneoscleral lamellar keratoplasty].

OBJECTIVE: To study the management of "no touch technique" surgical excision and corneoscleral lamellar keratoplasty in the treatment of corneo-conjunctival malignant melanoma. METHODS: Surgical excision for corneo-conjunctival malignant melanoma in six cases, from October 1989 to January 2004 in Zhongshan Ophthalmic Center, were performed. The entire tumors were removed in one piece without touching the tumor (no touch technique). The incision was outlined 4-6 mm outside the pigmented conjunctival mass, and 2 mm outside the corneal component. Dissecting deep enough without any tumor cell left to yield a tumor-free bed. After surgical incision, the host eyeball defect was covered with partial or total corneoscleral lamellar graft from fresh donor, and the conjunctiva defect was covered with or without amniotic membrane transplantation. All the patients were followed up to 6 months. RESULTS: The tumors in the remaining conjunctival margins were completely removed by local dissection combined with cryotherapy in the six cases. Three cases were treated with partial corneoscleral lamellar keratoplasty, two cases with total corneoscleral lamellar keratoplasty and one case with total corneoscleral lamellar keratoplasty plus amniotic membrane transplantation. All cases were subsequently treated with 0.01% thiotepa eyedrops and supplemental dacarbazine chemotherapy. At the average 43.5 months follow-up time (14.6 years to 6 months), no evidences of local recurrence of malignant melanoma or distant metastasis were observed. CONCLUSION: The clinical study suggests that using surgical excision of "no touch technique" to remove tumor in whole piece with corneoscleral lamellar keratoplasty is effective in the treatment of corneo-conjunctival malignant melanoma.

[The eyelid reconstruction in situ with allograft acellular dermal matrix].

OBJECTIVE: To explore the clinical value of allograft acellular dermal matrix in the treatment of eyelid defects. METHODS: From November 2001 to November 2002, 10 patients (8 male and 2 female; age varied from 14 to 47) with 11 eyelids were treated by eyelid reconstruction in situ with implantation of 1 mm thick allograft acellular dermal matrix. In 11 eyelids with defects, 2 was totally defect, 8 was 2/3 defect, 1 was 1/3 defect. In these 10 patients, 9 were injured and 1 was congenital. These defective eyelids included 8 upper lids, 1 lower lid and 1 case with both upper and lower lids. The average follow-up time was 8 months. RESULTS: In the follow-up periods, the inflammation of the eyelid was slight and no implants shedding or infection happened postoperatively. The conjunctiva grew well on the surface of the acellular dermal matrix. Histology examination showed neovascularization and presence of fibroblasts in the acellular dermal matrix 6 months after the operation. By the end of the follow up period, the results were excellent in 8 eyelids, good in 2 eyelids and improved in 1 eyelid. The efficacy rate of this treatment was 91%. CONCLUSIONS: Acellular dermal matrix can be used as a substitute of the tarsus in supporting the eyelid, it invokes little immunological and inflammatory reaction, and therefore, it can act as a biological scaffold to guide the growth of collagen and neovascularization.

[A clinical study of amniotic membrane transplantation for severe eye burns at the acute stage].

OBJECTIVE: To investigate the possibility of ocular surface reconstruction with amniotic membrane in the acute stage of burn injury, to compare the results using fresh and preserved amniotic membranes and to evaluate the surgical methods and their effects. METHODS: Consecutive patients of whole corneal burn above degree III with complete destruction of the limbus were divided into two groups to receive amniotic membrane transplantation (8 eyes of 8 patients with fresh amnion, 12 eyes of 11 patients with preserved one) or lamellar keratoplasty (24 eyes of 22 patients). The follow-up period was 12 to 26 months with an average of (15 +/- 2) months. RESULTS: The ocular surface became stabilized after the transplantation of amniotic membrane. In eyes treated with fresh amniotic membrane, the corneal surface was epithelized immediately. In eyes treated with preserved amniotic membrane, the corneal surface was epithelized only after 2 - 3 weeks. Lamellar keratoplasty was performed in 3 of 12 eyes with preserved amnion transplantation because the amnion was dissolved due to persistent epithelial defects. Amnions were absorbed with time and superficial neovascularization followed in the corneal surfaces. Seven of eight transplanted fresh amnions were absorbed within 2 to 8 months [mean time (4.3 +/- 0.8) months], and 10 of 12 preserved amnions were absorbed within 1 to 3 months [mean time (2.0 +/- 0.3) months]. The difference was statistically significant (t = 4.22, P < 0.01). The conjunctival surface was successfully reconstructed with amniotic membrane at the acute stage of burn injury. Moderate symblepharon occurred in one case only. Corneal dissolution never occurred in all patients who received lamellar keratoplasty, but recurrent erosion of corneal epithelium occurred in the grafts and corneal neovasularization developed eventually. Corneal graft had to be performed again on four eyes and symblapharonplasty had to be performed on seven eyes. Mild to medium symblepharon was observed in 5 of 24 eyes received lamellar keratoplasty. Visual acuity could be maintained at hand movement in eyes treated with amniotic membrane transplantation without secondary glaucoma and cataract. Visual acuity was figure counting in most cases with lamellar keratoplasty. CONCLUSIONS: Amniotic membrane transplantation (especially using a fresh membrane) can effectively reduce the inflammation of the cornea at the acute stage of burn injury, can prevent corneal ulcer and perforation and can make the stabilization process faster. It can also decrease corneal neovascularization as well as establish better conditions for successful keratoplasty.

[Long-term results of amniotic membrane transplantation for conjunctival surface reconstruction].

OBJECTIVE: To investigate the long-term results of amniotic membrane transplantation (AMT) for conjunctival surface reconstruction after symblepharon resection and analysis the related factors. METHODS: Fifty-one cases (55 eyes) with symblepharon due to eye burns (chemical or heat) or Stevens-Johnson syndrome were selected for symblepharon resection and AMT. Ten eyes were performed within 1 year and twenty-three eyes in 1.0 to 8.0 years after chemical eye burns. RESULTS: Observation time varied from 26.0 to 30.0 months [mean value (27.4 +/- 2.6) months]. No necrosis and ulceration were found in all amnion grafts at the early stage after transplantation. Deep conjunctival fornix and free of eye movement were obtained in 56.4% (31/55) of those eyes received surgery. Slight symblepharon recurrence and limited eye movement restrict were revealed in 16.4% of them (9/55), Fifteen eyes of them (27.3%) shown moderate recurrence of symblepharon. The effects of AMT for those patients with different degree of symblepharon had significant difference statistically (Pearson Chi-Square, P = 0.000). The same results were observed between those patients who were performed in different time after chemical eye burns (Likelihood Ratio, P = 0.039) and with different severity of dry eye (Pearson Chi-Square, P = 0.000). CONCLUSIONS: Amniotic membrane can be used to reconstruct ocular surface effectively, but multiple surgeries may be needed. These microenvironments such as symblepharon severity, dry eye, and whether remained partial healthy conjunctiva in the affected eyes before surgery will influence the long-term results of AMT for conjunctival surface reconstruction.

Fresh amniotic membrane transplantation combined lamellar keratoplasty for patients with recurrent Mooren's ulcer.

PURPOSE: To investigate the possibility of amniotic membrane as an immunological insulating band to reduce the recurrent frequency of Mooren's ulcer. METHODS: Twelve cases(12 eyes) with recurrent Mooren's Ulcer were observed. Among them, 4 cases (4 eyes) were male and 8 cases(8 eyes) female, ranging in age between 26 and 51 years [mean(41 +/- 3) years]. Three eyes recurred once, 5 eyes twice, and 4 eyes three before. Eleven of 12 cases (11/12 eyes) with frequently recurrent Mooren's ulcer underwent lamellar keratoplasty combined amniotic membrane transplantation (AMT). One patient who had entire corneal ulceration accepted AMT alone. RESULTS: Follow-up time is 12 to 29 months, [mean (23 +/- 6) months]. Before AMT, the recurrent frequency of Mooren's Ulcer of all cases after corneal surgery was 1-7 months [mean (3 +/- 2) months]. Nine of 12 eyes with lamellar keratoplasty combined AMT did not recur within the observation period; 2 eyes recurred 11 months after the surgery. Three months postoperatively, neovascularization was observed, which made it nearly impossible to decipher between amniotic membrane and its nearby conjunctiva, only at the junction of the transplant can some trails be observed. One case with entire AMT alone showed graft resolution and neovascularization in 1 month. CONCLUSION: AMT combined with lamellar keratoplasty and lesion excision may delay recurrence of Mooren's Ulcer, reduce its recurrent frequency. Besides the effects of decreasing inflammation, it may have immunological insulating function as well. This conclusion should be proven by further clinical comparative study of much more samples.

[Clinical characteristics of patients with dry eye syndrome].

OBJECTIVE: To learn the clinical characteristics of patients with dry eye syndrome. METHODS: The following items were recorded in 115 patients (229 eyes) with dry eye, including symptoms, causation, systematic diseases, slit-lamp examination, tear break-up time, basal and reflex Schirmer's test, vital staining (fluorescent and rose bangle) and meibomian gland dysfunction examination. Rheumatoid factor and auto-antibody detection were performed in Sjögren's syndrome suspected patients. RESULTS: Aqueous tear deficiency (ATD, 48.7%) ranked the most common type, followed by over-evaporation dry eye (34.8%), mixed type (13.9%) and conjunctivochalasis (3.5%). In all the causes of the dry eye, about 11.3% had Sjögren syndrome (SS). Females suffering from dry eye were more than males, especially SS. Dryness was the most common symptom (84.0%), especially in ATD patients, then followed by ocular fatigue (72.0%), foreign body sensation (64.0%) and impairment of vision (56.0%). The ocular irritation was more severe in meibomain gland dysfunction (MGD) patients than in ATD patients. Among the results of tear break-up time (BUT), rose bangle (Rb) staining and fluorescent (Fl) staining in all types of dry eye, significant relationship was found among them, especially between Rb and Fl score (r = 0.612, P = 0.000). SS patients had much more severe abnormality in all the four signs than non-SS aqueous tear deficiency (NSTD) and MGD patients. However, in the comparisons of BUT, Rb and Fl between NSTD and MGD patients, there were no significant differences. CONCLUSION: Symptoms combined with examinations of BUT, Schirmer's test, Fl and Rb staining and meibomian gland function are the necessary means to diagnose most of the dry eye patients.

Microsurgical treatment of Mooren's corneal ulcer.

This study evaluated the effect of microsurgery of lamellar keratoplasty (LKP) on Mooren's corneal ulcer. The surgical effect, postoperative astigmatism, postoperative vision, postoperative ulcer recurrence, and surgical complications of 2 groups of consecutive Mooren's ulcer inpatients treated respectively by non-microsurgery of LKP and microsurgery of LKP were analyzed. There were significant differences of the effect, postoperative astigmatism, postoperative vision, postoperative ulcer recurrence, and surgical complications between the 2 groups. The effect and postoperative vision of the microsurgery-treated group were better than those of the non-microsurgery-treated group. The postoperative astigmatism, postoperative ulcer recurrence, and surgical complications of the microsurgery-treated group were less than those of the non-microsurgery-treated group. Microsurgery of LKP of Mooren's corneal ulcer can greatly improve the cure rate of the disease and postoperative vision, and reduce surgical complication and postoperative ulcer recurrence.

[Confocal microscopy in transplanted human corneas].

PURPOSE: The aim of the study was in-real time observation and morphological evaluation of the transplanted human corneas, using confocal 2.0 microscopy. METHODS: Twelve eyes of 12 patients on 3-7 days after lamellar keratoplasty (LKP), 8 eyes of 8 patients at 1 year after LKP, and 10 eyes of 10 patients at 3-7 days after penetrating keratoplasty (PKP), 11 eyes of 11 patients at 1 year after PKP were examined by confocal 2.0 microscopy in vivo. Images were recorded by continuously focusing the optical section through the full thickness central cornea. RESULTS: 3-7 days after LKP, small stromal cells, cranny-like dark strias and nerves were seen in transplanted corneas. There were highly reflective regions and dots in the lamellar interface. One year after LKP, the nerves disappeared. There were less highly reflective regions, but the dots still can be seen. Some gross dark strias were seen in the posterior stroma and the density of the endothelium cells was normal. 3-7 days after PKP, keratocytes were activated. Nerves and gross dark strias could be seen in transplanted corneas. The density of the endothelium cells was normal, with some highly reflective dots deposited among them. One year after PKP, the nerves disappeared, and strias still existed. The density of the endothelium cells decreased significantly. CONCLUSIONS: Confocal scanning microscopy is a new tool for the study of cellular morphology and construction of transplanted human corneas. It can be used in the evaluation of operation effect, clinical observation and follow-up.

[The contralateral eye in patients with unilateral iridocorneal endothelial syndrome].

OBJECTIVE: To study the clinical characteristics of the contralateral eyes in patients with unilateral iridocorneal endothelial syndrome (ICE). METHODS: The clinical characteristics were analyzed retrospectively on the contralateral eyes in 42 cases of unilateral ICE. Among them, 19 patients (19 eyes) received examinations of refraction, intraocular pressure (IOP), slit lamp, gonioscopy and ultrasound biomicroscopy. In the 35 cases (35 eyes), the endothelial cell counts of the contralateral eyes were compared with age-matched normal controls using t-test. RESULTS: In the 19 cases of unilateral ICE syndrome, emmetropia or hypermetropia were found in 88.9%, IOP higher than 21 mm Hg was present in one case, and anterior chamber depth lower than 2.2 mm was in 50.0%. Atrophy or dysplasia of iris existed in 3 cases, there were narrowness and/or adhesion of anterior chamber angle in 3 cases and pyramidal adhesion under gonioscopy and/or ultrasound biomicroscopy examination in 2 cases. One case represented relative paracentral scotoma in the visual field examination. Systematic disorders, including hepatitis B, diabetes, hyperthyroidism, duodenum ulceration, hypertension were found in 31.6%. In the 35 patients who received endothelial cell count, the average endothelial cell density of the contralateral eyes was (2 593.4 +/- 432.7)/mm(2), which was significantly lower than that of the normal controls (2 784.9 +/- 280.6)/mm(2) (t = -2.43, P = 0.019). The hexagonality and coefficient variation of cell size of ICE patients did not differ from that of the normal controls. CONCLUSIONS: The contralateral eye in cases diagnosed as unilateral ICE syndrome may be subclinically involved, so it is necessary to pay attention to the contralateral eye, and follow up all the patients suffered from ICE syndrome.

[Expression of vascular endothelial growth factor and its receptors (flt-1) in morbid human corneas and investigation of its clinic importance].

PURPOSE: To investigate the expression of vascular endothelial growth factor (VEGF) and its receptor (flt-1) in morbid corneas and the potential effects. METHODS: Eleven cases of normal peripheral corneas and limbal tissues and 32 cases of miscellaneous morbid corneas were collected during corneal transplantation. The specimens were sectioned in a cryostat and stained with streptavidin-biotin-peroxidase method for VEGF and flt-1. The expressive levels of VEGF were compared with grades of patients' clinical manifestations. RESULTS: Positive expression of VEGF was exclusively presented in all morbid corneal specimens and that of flt-1 was showed in most cases. Stronger staining was found in the epithelia and stoma of the morbid cornea. The expressive levels of VEGF were more important in the stroma and the endothelia of the morbid corneas than that in the normal peripheral corneas and were positively correlated with the degrees of corneal opacities and the area of corneal neovascularization in infiltrating inflammatory cells and proliferative tissues ( P < 0. 05). CONCLUSIONS: VEGF and flt-1 were expressed in miscellaneous morbid corneas and may play an important role in the repair of corneal injuries and the corneal neovascularization.

[Corneal topography and thickness in keratoconus].

OBJECTIVE: To evaluate the corneal topography and pachymetry in keratoconus. METHODS: Thirty-five patients (47 eyes) with keratoconus were evaluated by Orbscan corneal topography system. The location, anterior and posterior surface elevation, curvature and pachymetry were analyzed with special reference to the central point of cornea, the apex, the highest point of posterior surface, the point with greatest curvature and the thinnest point. The correlation between the point of greatest curvature and the apex was also analyzed. RESULTS: The mean elevation of the apex was (0.102 +/- 0.044) mm, the mean distance between the apex and the central point of cornea was (0.686 +/- 0.376) mm. Most of the apexes, the points with the highest posterior surface, the points with the greatest curvature were located in the inferior temporal quadrant, followed by inferior nasal, superior temporal and superior nasal quadrant. The SimK of keratocunus was (60.9 +/- 10.4/53.4 +/- 8.7) D and the mean powers within 3 mm and 5 mm were (57.1 +/- 8.0) D and (50.7 +/- 5.4) D respectively. High correlation between apex elevation and the apex curvature was found (r = 0.697, P < 0.01), and there was also negative relationship between apex elevation and corneal thickness (r = -0.563, P < 0.01). CONCLUSIONS: The Orbscan system can provide accurate and subtle information about the shape and thickness of keratoconus, which can help us to learn this disorder deeply, especially in the early diagnosis of this disease.