Comparison of manual and automated endothelial cell density analysis in normal eyes and DSEK eyes.

PURPOSE: To compare automated endothelial cell density analysis with manual cell detection methods with 3 imaging devices. METHODS: In this prospective study, the corneal endothelium of 54 Descemet stripping endothelial keratoplasty (DSEK) eyes and 28 normal eyes was analyzed with a Nidek Confoscan 4 confocal microscope using a 20× noncontact lens and with Tomey EM-3000 and Konan Noncon Robo SP-8800 specular microscopes. Testing order was randomized. The Confoscan and Robo images were presented in a blinded fashion to an experienced technician for manual cell identification and analysis using the manufacturer's software. A different operator determined endothelial cell density using fully automated software associated with each imaging device. Agreement between methods was assessed by repeated-measures analysis of variance and post hoc Tukey analysis. RESULTS: Manual cell identification on Robo and Confoscan 4 images produced comparable cell density measurements in normal eyes (P = 0.73) and DSEK eyes (P = 0.11). The Confoscan automated cell detection software differed significantly from manual cell detection in both normal and DSEK eyes (P = 0.0003 and P < 0.0001, respectively). The Robo automated cell detection software produced results comparable with manual cell detection in normal eyes (P = 0.082) but significantly overestimated cell density in DSEK eyes (P < 0.0001). The EM-3000 automated cell detection produced results comparable with manual cell detection in normal eyes (P = 0.067) and DSEK eyes (P = 0.49). CONCLUSIONS: Only 1 of 3 automated cell detection programs produced cell density readings comparable with those obtained with manual cell identification; the other 2 automated programs significantly overstated endothelial cell density in DSEK eyes.

Photoactivated riboflavin treatment of infectious keratitis using collagen cross-linking technology.

PURPOSE: To evaluate riboflavin/ultraviolet-A (UVA) as an adjunct treatment for infectious keratitis. METHODS: This prospective, dual-center, interventional case series included cases of infectious keratitis that were treated by instilling riboflavin 0.1% solution for 30 minutes to saturate the cornea, followed by exposure to 365-nm UVA light (3 mW/cm(2)) for 15 to 45 minutes, with continued instillation of riboflavin. Eyes continued on standard antibiotic treatment. The primary outcome measures were the times to resolution of the infiltrate and the epithelial defect. RESULTS: Forty patients aged 14 to 86 years were enrolled. Seven (18%) eyes had a previous keratoplasty. Bacterial species were identified in 24 eyes, fungal in 7, protozoan in 2, viral in 1, and no organism in 6. The maximum infiltrate diameter ranged from 1 to 12 mm and the epithelial defect diameter was 0 to 8 mm before treatment. In 6 cases (2 bacterial, 3 fungal, and 1 without growth), the keratitis did not resolve successfully and the eye received a penetrating keratoplasty (PK). In 1 eye with prior PK, the infection resolved following treatment, but a regraft was required to address perforation of the PK incision. CONCLUSIONS: Riboflavin/UVA should be avoided in eyes with prior herpes simplex but otherwise posed no obvious safety risk in this series and appeared to be most effective when the infection depth was limited. The success rate was higher for bacterial infections than fungal infections. Randomized studies against antibiotics alone are needed to further evaluate efficacy.

Descemet's stripping endothelial keratoplasty five-year graft survival and endothelial cell loss.

PURPOSE: To assess 5-year Descemet's stripping endothelial keratoplasty (DSEK) graft survival and endothelial cell loss in the surviving grafts. DESIGN: Retrospective, interventional case series. PARTICIPANTS: One hundred sixty-five eyes of 149 patients treated with primary DSEK. METHODS: Donor corneal-scleral rims were dissected manually or with a microkeratome and were cut with a trephine. The graft was folded endothelial side inward and was inserted with forceps through a 5-mm incision. The cumulative probability of secondary graft failure was calculated using Kaplan-Meier survival analysis and the log-rank test. Endothelial cell density (ECD) was determined from baseline preoperative donor and 1-year, 3-year, and 5-year postoperative central endothelial images. MAIN OUTCOME MEASURES: Graft survival and ECD at 5 years. RESULTS: The median recipient age was 71 years (range, 22-90 years) and 62% were female. Eighteen eyes (11%) were treated for pseudophakic or aphakic corneal edema and 147 eyes (89%) were treated for Fuchs' dystrophy. The cumulative 5-year survival rate was significantly lower in pseudophakic or aphakic corneal edema eyes (76%) versus Fuchs' eyes (95%; P = 0.0087). In particular, the 5-year survival rate was reduced significantly in eyes with prior glaucoma shunt or trabeculectomy surgery vs. those without (40% vs. 95%; P<0.0001). The causes of secondary graft failure were endothelial decompensation in 6 eyes (3.6%) and unsatisfactory corrected distance acuity (20/60 to 20/100) in 4 eyes (2.4%). No grafts experienced traumatic wound rupture or failed as a result of ocular surface complications. The median 5-year endothelial cell loss was 53% (range, 7.5%-89%). The 5-year graft ECD was correlated weakly with the baseline donor ECD (r = 0.22 and P = 0.04) and was not significantly correlated with recipient gender (P = 0.075), age (P = 0.85), or diagnosis (P = 0.78). CONCLUSIONS: The 5-year graft survival rates for DSEK were similar to those reported for penetrating keratoplasty in the multicenter Cornea Donor Study (95% vs. 93% for Fuchs' dystrophy and 76% vs. 73% for pseudophakic or aphakic corneal edema). Furthermore, the 5-year endothelial cell loss after DSEK compared favorably with that measured after penetrating keratoplasty in the Cornea Donor Study (53% vs. 70%).

Prospective study of visual outcomes and endothelial survival with Descemet membrane automated endothelial keratoplasty.

PURPOSE: To evaluate vision and endothelial cell survival in an initial Descemet membrane automated endothelial keratoplasty (DMAEK) series. METHODS: This was a prospective nonrandomized study of an initial consecutive series of 40 DMAEK cases, performed with or without concomitant phacoemulsification and intraocular lens implantation. The graft was dissected with a microkeratome. A central 6- to 7-mm big bubble was created to separate endothelium from stroma, and the overlying stroma was excised. The graft was cut to 8.5- to 9.5-mm diameter and inserted with a pull through technique. Eyes were treated for Fuchs endothelial dystrophy, secondary corneal decompensation, or previous failed endothelial transplant. Best spectacle-corrected visual acuity, manifest refraction, pachymetry, and endothelial cell density were assessed. RESULTS: Median best spectacle-corrected visual acuity was 20/30 at 1 month (range: 20/15-20/50), improved from 20/40 (range: 20/25-20/400) preoperatively, excluding 7 eyes (18%) with significant retinal pathology. Rates of 20/20, 20/25, 20/30, and 20/40 vision were 25%, 71%, 89%, and 100%, respectively, at 3 months and 48%, 74%, 93%, and 100%, respectively, at 6 months. Median endothelial cell loss relative to baseline donor cell density was 31% at 6 months. Air was reinjected in 10 eyes (25%) to promote graft attachment, and 2 grafts (5%) failed to clear. CONCLUSIONS: DMAEK provided significant improvement in visual acuity and marked reduction in central corneal thickness. DMAEK had a higher rate of postoperative air reinjection than Descemet stripping endothelial keratoplasty and comparable 6-month endothelial cell loss.

Rate and risk factors for cataract formation and extraction after Descemet stripping endothelial keratoplasty.

PURPOSE: To assess the rate and risk factors for cataract formation and extraction after Descemet stripping endothelial keratoplasty (DSEK). METHODS: An initial, consecutive series of 1050 primary DSEK procedures was reviewed to identify eyes that remained phakic. Only the first-treated eye of each patient was included; 60 eyes qualified. Rate and risk factors for subsequent cataract formation and extraction were assessed by multivariate proportional hazards modelling and survival analysis. RESULTS: Median patient age was 52 years (range: 32-69 years), and median graft diameter was 8.5 mm (range: 8-9 mm). Median follow-up was 32 months (range: 1-51 months). Cataract extraction was performed after DSEK in 22 eyes (37%) without complication and all grafts remained clear with median follow-up of 18 months (range: 1-44 months). Six eyes were regrafted; all underwent cataract extraction either simultaneously (n = 4) or subsequently (n = 2). At 1 and 3 years, respectively, the probability of cataract extraction was 0% and 7% in patients who were 50 years or younger at the time of DSEK (n = 20) versus 31% and 55% in older patients (n = 40), a statistically significant difference (p = 0.0005). CONCLUSIONS: Rates of cataract formation and extraction after DSEK were significantly higher in patients over 50 years of age and substantially exceeded normal population rates.

Descemet's membrane endothelial keratoplasty: prospective multicenter study of visual and refractive outcomes and endothelial survival.

PURPOSE: To describe Descemet's membrane endothelial keratoplasty (DMEK) techniques, perioperative challenges, management, and visual and refractive outcomes. DESIGN: Prospective, multicenter, consecutive case series. PARTICIPANTS: Sixty eyes of 56 patients with Fuchs' endothelial dystrophy, pseudophakic bullous keratopathy, or failed previous graft. INTERVENTION: Descemet's membrane (DM) and endothelium were stripped from donor corneas submerged in corneal storage solution in a corneal viewing chamber. Donor DM diameters were 8.5 or 9.0 mm. The central 7 mm of DM was stripped from the recipient cornea. After staining with trypan blue to improve visualization, donor DM was inserted through a 2.8-mm incision. Descemet's membrane endothelial keratoplasty was performed alone (n = 48) or was combined with phacoemulsification and lens implantation (n = 11), pars plana vitrectomy (n = 2), or both. MAIN OUTCOME MEASURES: Best spectacle-corrected visual acuity (BSCVA), manifest refraction, and endothelial cell density. RESULTS: Median BSCVA was 20/30 at 1 month (range, 20/20-20/60), improving from 20/50 (range, 20/25-hand movements) before DMEK, excluding 4 eyes (7%) with preexisting ocular pathologic features that limited visual potential. At 3 months, 26% had 20/20 vision, 63% saw 20/25 or better, and 94% saw 20/40 or better. Refractive cylinder remained unchanged at 0.9 diopters (D; P = 0.93), and a hyperopic shift of 0.49+/-0.63 D (P = 0.0091) was noted in DMEK single procedures. Endothelial cell loss was 30%+/-20% at 3 months and 32%+/-20% in 38 eyes that reached the 6-month examination. Median pachymetry decreased from 660 mum before surgery to 530 mum. Descemet's membrane stripped successfully from 60 of 72 donor corneas; 6 were converted successfully to Descemet's stripping automated endothelial keratoplasty (DSAEK) and 6 (8%) were discarded. Only 1 graft detached completely, but air was reinjected in 38 eyes (63%), mainly for partial detachments. Five DMEK corneas (8%) failed to clear and were replaced successfully with DMEK or DSAEK. All remained clear at last follow-up. CONCLUSIONS: Compared with DSAEK, DMEK provided a significantly higher rate of 20/20 and 20/25 vision, with comparable endothelial cell loss. Descemet's membrane endothelial keratoplasty restored physiologic pachymetry, but donor preparation and attachment currently are more challenging than with DSAEK.