Outcomes of Repair of Total Graft Detachment following Descemet's Membrane Endothelial Keratoplasty. / Rettungsversuche einer vollständigen Transplantatablösung nach Descemet-Membran-Endothelkeratoplastik.

OBJECTIVE: To present the outcomes of attempts to salvage total graft detachment following Descemet's membrane endothelial keratoplasty (DMEK). METHODS: A search of the electronic medical records of two tertiary medical centers for all patients who underwent DMEK yielded six cases of postoperative total graft detachment (2.54%). Graft salvage was attempted in all cases using repeated intracameral graft staining, unfolding, and reattachment to the stroma under 20% hexafluoride gas. RESULTS: In all cases, a free-floating totally detached graft was identified in the anterior chamber shortly after surgery. Salvage surgery resulted in a central, well-oriented, and fully attached graft. In three cases, the primary graft failed, and in two, the corneas cleared at first but failed after 2 months and 1 year respectively. In one case, the cornea remained clear during 1 year of follow-up but had a very low endothelial cell density. CONCLUSION: Reattachment of fully detached DMEK graft is technically possible, but graft manipulation during the primary and secondary operations is likely to damage the endothelial cells, resulting in primary or early graft failure. If graft salvage is attempted, the probability of primary or early graft failure should be discussed with the patient, and expectations should be tempered accordingly.

Active sensory substitution allows fast learning via effective motor-sensory strategies.

We examined the development of new sensing abilities in adults by training participants to perceive remote objects through their fingers. Using an Active-Sensing based sensory Substitution device (ASenSub), participants quickly learned to perceive fast via the new modality and preserved their high performance for more than 20 months. Both sighted and blind participants exhibited almost complete transfer of performance from 2D images to novel 3D physical objects. Perceptual accuracy and speed using the ASenSub were, on average, 300% and 600% better than previous reports for 2D images and 3D objects. This improvement is attributed to the ability of the participants to employ their own motor-sensory strategies. Sighted participants dominant strategy was based on motor-sensory convergence on the most informative regions of objects, similarly to fixation patterns in vision. Congenitally, blind participants did not show such a tendency, and many of their exploratory procedures resembled those observed with natural touch.

Short-term anterior chamber inflammation in phacoemulsification with and without Ex-Press glaucoma implant.

PURPOSE: The aim of this study was to investigate the incidence of clinically significant anterior chamber inflammation in a combined surgery, namely, phacoemulsification and Ex-Press miniature glaucoma device implantation, compared to phacoemulsification alone. METHODS: A retrospective comparative study of a consecutive series of 210 participants above 18 years of age diagnosed with significant cataract and who required glaucoma surgery, namely, Ex-Press miniature glaucoma device implantation or cataract alone in one or both eyes. All were operated on by a single experienced glaucoma surgeon in a single medical center. A total of 231 eyes were included in this study. All cases underwent an uneventful surgery and were examined the day following the surgery for visual acuity, intraocular pressure, and signs of excessive anterior chamber inflammation (Standardization of Uveitis Nomenclature grading ⩾ 3). RESULTS: The combined group included 55 eyes of 51 patients, of whom 15 (27.3%) demonstrated excessive anterior chamber inflammation. The phacoemulsification group included 176 eyes of 159 patients, of whom 12 (6.7%) demonstrated excessive anterior chamber inflammation. Visual acuity and intraocular pressure measurements showed no statistically significant difference between the two groups. CONCLUSION: The Ex-Press glaucoma device is efficient, safe, and known for its inert nature. However, combination of this procedure with phacoemulsification surgery might result in a condition encouraging excessive inflammation, which eventually could lead to excessive anterior chamber inflammations if not treated vigorously. Emphasizing and recognizing the risks, especially in glaucoma patients, is important.

Anterior Segment Optical Coherence Tomography of Post-Descemet Stripping Automated Endothelial Keratoplasty Eyes to Evaluate Graft Morphology and Its Association With Visual Outcome.

PURPOSE: To evaluate the relationship between graft thickness/regularity and visual outcomes of Descemet stripping automated endothelial keratoplasty (DSAEK). METHODS: Records of post-DSAEK patients who were examined by anterior segment optical coherence tomography at "Villa Igea" Private Hospital (Forlì, Italy) since April 2015 were reviewed. Pachymetric and elevation maps of both host cornea and graft were analyzed. Graft regularity was determined based on the root mean square error (RMSE) of the graft pachymetric measurements taken 3 and 6 mm from the center and the RMSE of the corneal elevation measurements at its posterior and interface surfaces. These parameters were correlated with best-spectacle-corrected visual acuity (BSCVA) (expressed in logarithm of the minimum angle of resolution) and compared between eyes with central graft thickness (CGT) ≥100 µm (group 1) and eyes with CGT <100 µm (group 2). RESULTS: Eighty-nine post-DSAEK eyes of 89 patients with Fuchs endothelial dystrophy or bullous keratopathy and no significant comorbidities were included. There were 40 eyes (CGT = 138.2 ± 31.7 µm) in group 1 and 49 eyes (CGT = 73.3 ± 15.5 µm) in group 2. The RMSEs of graft pachymetry and the RMSEs of the interface and posterior surface elevation maps at 3 and 6 mm differed significantly between both groups (P < 0.05). When only eyes with Fuchs endothelial dystrophy (n = 54) were considered in both groups, there was a statistically significant correlation (r = 0.44; P = 0.001) between BSCVA and CGT. CONCLUSIONS: DSAEK grafts thinner than 100 µm are more regular than thicker ones. In eyes with Fuchs endothelial dystrophy that are otherwise healthy, thinner grafts yield significantly better BSCVA.

Outcomes of ultrathin Descemet stripping automated endothelial keratoplasty (UT-DSAEK) performed in eyes with failure of primary Descemet membrane endothelial keratoplasty (DMEK).

AIM: To evaluate the outcomes of ultrathin Descemet stripping automated endothelial keratoplasty (UT-DSAEK) performed in eyes after failure of primary Descemet membrane endothelial keratoplasty (DMEK). METHODS: This was a retrospective, non-comparative interventional case series done in a tertiary care hospital. The study group included 21 eyes of patients which underwent UT-DSAEK following the failure of primary DMEK. Outcome measures included best spectacle-corrected visual acuity (BSCVA) and endothelial cell density (ECD) both recorded 6 and 12 months postoperatively as well as central graft thickness (CGT) measured 6 months after UT-DSAEK. RESULTS: When considering only eyes without comorbidities (17 of 21), 12 months after UT-DSAEK, BSCVA was ≥20/25 in 12/13 (92%) eyes and ≥20/20 in 4/13 (30%) eyes. Mean ECD loss rate was 38.9% at 12 months postoperatively (range 8%-57%). Six months postoperatively, CGT averaged at 81±34 µm (range 34-131 µm). No intraoperative complications were recorded. Postoperatively, one patient (no. 8) had graft wrinkles that were fixed 2 days following UT-DSAEK. Four patients have developed intraocular lens (IOL) opacification, and two of them underwent IOL exchange. No other postoperative complications were recorded. CONCLUSIONS: UT-DSAEK is instrumental in the management of primary DMEK graft failure, allowing visual rehabilitation which is comparable with that of repeat DMEK.

Clinical Efficacy and Safety of the EX-PRESS Filtration Device in Patients with Advanced Neovascular Glaucoma and Proliferative Diabetic Retinopathy.

BACKGROUND: The prognosis of conventional filtration surgery in eyes with neovascular glaucoma (NVG) is limited due to increased fibrovascular proliferation or bleeding. This study aims to evaluate the safety and efficacy of the EX-PRESS filtration device in the management of NVG associated with proliferative diabetic retinopathy (PDR). METHODS: In this retrospective case series, we reviewed the medical records of patients diagnosed as having NVG associated with PDR who underwent EX-PRESS filtration surgery. The main outcome measures were: postoperative intraocular pressure (IOP), the percent of IOP drop, the number of glaucoma medications, visual acuity, and complications of surgery. Successful surgery was defined as an IOP <22 mm Hg and >5 mm Hg with or without additional glaucoma surgery, and no loss of light perception or less than a 2-line decrease on the Snellen chart of the best corrected visual acuity (BCVA). RESULTS: Five patients (5 eyes) were included in this study. The mean preoperative IOP was 33.4 ± 5.9 mm Hg compared to an IOP of 17.0 ± 3.0 mm Hg at the last follow-up (p = 0.003). The mean number of preoperative anti-glaucoma medications was 3.8 ± 0.4 compared to 2.2 ± 1.5 (p = 0.06) at the last follow-up visit. Final visual acuity improved or stabilized within 1 Snellen line in all 5 patients. Three patients had a "hypertensive phase" (defined as an IOP >21 mm Hg during the first 6 postoperative months) which resolved within 2 months. Two patients developed a hyphema that resolved spontaneously. None of the patients experienced any serious complications. CONCLUSION: EX-PRESS filtration device has a good IOP-lowering effect and a low rate of complications in patients with advanced NVG associated with PDR. In addition, there was no loss of light perception or no line decrease of the BCVA.

Correlation between central corneal thickness and myopia.

PURPOSE: To analyze the correlation between central corneal thickness (CCT) and myopia in refractive surgery candidates. MATERIALS AND METHODS: Patients that underwent myopic laser refractive surgery between January 2000 and December 2014 were included. Preoperative CCT was measured by ultrasonic pachymetry, and refractive status determined by manifest and cycloplegic refraction. RESULTS: A total of 30,245 individuals were included. Mean age was 28.2 ± 8.6 years, and 45.9% were female. Mean refractive error was 4.02 ± 2.17 D (range 0.25-19.5), and the mean CCT measurement was 533.5 ± 35.5 µm (range 404-794). Younger individuals showed higher degree of myopia (p = 0.006). No difference in CCT was found between women and men (533.0 ± 35.1 and 533.6 ± 35.9 µm, respectively, p = 0.19). Though CCT showed no correlation with age (p = 0.226) participants above age 40 expressed higher CCT values (p < 0.001). No significant correlation was found between the CCT and cylinder (p > 0.05). An increase in mean keratometry was associated with a decrease in CCT (p < 0.001). There was a direct correlation between the degree of myopia and CCT (r = 0.94, p < 0.001). The result remained the same after adjusting for age group and gender in stepwise backward regression analysis (p < 0.001). CONCLUSION: Central corneal thickness is correlated with the degree of myopia among adults undergoing refractive surgery.

Deep Anterior Lamellar Keratoplasty After Descemet Stripping Automated Endothelial Keratoplasty.

PURPOSE: To report the indications and long-term outcomes of deep anterior lamellar keratoplasty (DALK) performed after Descemet stripping automated endothelial keratoplasty (DSAEK) in cases of visually significant stromal opacities. DESIGN: Retrospective, interventional, consecutive case series. METHODS: Setting: Private hospital. STUDY POPULATION: Thirteen eyes that underwent DALK after DSAEK at our institution. Indications for DALK after DSAEK included both stromal opacities persisting after DSAEK and stromal opacities occurring secondarily in post-DSAEK corneas. DALK was always performed in a standardized fashion including exchange of a disc of full-thickness recipient cornea (up to the DSAEK stromal surface),7.0 mm in diameter, with a donor lamella obtained by microkeratome-assisted dissection, punched to 7.0 mm and sutured into place with a double running 10-0 nylon suture. MAIN OUTCOME MEASURES: Best spectacle-corrected visual acuity (BSCVA), manifest refraction, and endothelial cell density (ECD). RESULTS: Mean follow-up was 26 ± 18 months (range = 6-60 months). Indications for DSAEK were full-thickness graft failure (n = 8), DSAEK graft failure (n = 3), and pseudophakic bullous keratopathy (n = 2). Indications for subsequent DALK were persisting stromal opacity (n = 9) and stromal opacities newly occurred after DSAEK as a result of HSV keratitis (n = 2) or interface infection (n = 2). After complete suture removal, mean BSCVA was 20/28 (0.14 ± 0.8 logMAR) in eyes without ocular comorbidities affecting visual acuity (n = 7), while refractive astigmatism was within 4 diopter (D) in all but 1 eye (average = 3.2 ± 1.4 D). No intraoperative complications were recorded. CONCLUSIONS: Performing DALK on DSAEK eliminates the need for open-sky surgery, achieving visual results comparable to those of penetrating keratoplasty, while sparing a healthy endothelial graft.

Comparison of Fluorescence Microscopy and Different Growth Media Culture Methods for Acanthamoeba Keratitis Diagnosis.

Acanthamoeba keratitis (AK), a potentially blinding infection of the cornea, is caused by a free-living protozoan. Culture and microscopic examination of corneal scraping tissue material is the conventional method for identifying Acanthamoeba. In this article, we compared several methods for AK diagnosis of 32 patients: microscopic examination using fluorescent dye, specific culture on growth media-non-nutrient agar (NNA), culture on liquid growth media-peptone yeast glucose (PYG), and TYI-S-33. AK was found in 14 patients. Thirteen of the specimens were found AK positive by fluorescence microscopic examination, 11 specimens were found AK positive on PYG growth media, and 9 specimens were found AK positive on TYI-S-33 growth media. Only five specimens were found AK positive on NNA growth media. Therefore, we recommend using fluorescence microscopy technique and culture method, especially PYG liquid media.

Acanthamoeba keratitis: study of the 5-year incidence in Israel.

BACKGROUND: Acanthamoeba keratitis (AK) is not a notifiable disease in Israel, so there are no accurate incidence rates for this condition in Israel. The aim of this study was to estimate the incidence of AK in Israel for the years 2008-2012. METHODS: We distributed a survey questionnaire to laboratory managers in Israel. The laboratories were affiliated to medical institutes that either provided ophthalmology services or served community ophthalmology clinics. Our questionnaire requested survey respondents to provide information regarding the methods used to diagnose AK, and the number of positive and negative cultures for Acanthamoebae species performed for each of the years from 2008 to 2012. RESULTS: Six laboratories used non-nutrient agar with Escherichia coli as the culture medium, one used calcofluor-white staining with fluorescent microscopy, and two used PCR for diagnosing AK. Twenty-three AK cases were identified, to give an estimated incidence of 1/1 668 552. CONCLUSIONS: AK is mostly attributable to the use of contact lenses. As contact lenses are popular in Israel, we expected a higher incidence rate. A lower than expected incidence rate may indicate insufficient awareness of AK in Israel.

External Ophthalmomyiasis Caused by a Rare Infesting Larva, Sarcophaga argyrostoma.

Purpose. External ophthalmomyiasis (EO) is caused by infesting larvae belonging to various species of flies. Most documented cases result from sheep (Oestrus ovis) and Russian (Rhinoestrus purpureus) botfly larvae, but we recently discovered a rare case of EO caused by flesh fly (Sarcophaga argyrostoma) larvae. Here, we report the case of a patient with EO who had been hospitalized and sedated for 1 week because of unrelated pneumonia. Methods. Case report. Results. A total of 32 larvae were removed from the adnexae of both eyes. Larvae identification was confirmed through DNA analysis. Treatment with topical tobramycin resulted in complete resolution of EO. Conclusion. EO can be caused by S. argyrostoma, and the elderly and debilitated may require extra ocular protection against flies during sedation.

Foreign body embedded in anterior chamber angle.

Introduction. We present a case of a metallic foreign body embedded in the anterior chamber angle. After standing in close proximity to a construction worker breaking a tile, a 26-year-old woman using soft contact lens for the correction of mild myopia presented to emergency department for evaluation of a foreign body sensation of her right eye. Methods and Results. Diagnosis was confirmed by gonioscopic examination and a noncontrast CT scan of head and orbits. The foreign body was removed by an external approach without utilizing a magnet. The patient's final outcome was favorable. Discussion. The above is a rare clinical situation, which is impossible to detect on slit-lamp examination without a gonioscopic view. Proper imaging and a specific management are mandatory in order to achieve favorable outcome.

Endogenous endophthalmitis with an unusual infective agent: Actinomyces neuii.

PURPOSE: To report an unusual case of a patient with endogenous endophthalmitis caused by Actinomyces neuii. METHODS AND RESULTS: A 69-year-old woman in an immunosuppressed state and who had a previous history of periappendicular abscess presented with bilateral red painful eyes. The diagnosis was confirmed by culture and pan-bacterial polymerase chain reaction drawn from anterior chamber sample. On admission, the patient underwent an intravitreal injection of vancomycin combined with ceftazidime. Following a 3-week treatment of intravenous penicillin and topical sulfacetamide sodium, the patient recovered fully. CONCLUSIONS: Actinomyces neuii can cause endogenous endophthalmitis. Intravenous penicillin G is an effective treatment leading to favorable prognosis.