Clinical Outcomes and Lens Constant Optimization of the Zeiss CT Lucia 602 Lens Using a Modified Yamane Technique.

PURPOSE: To report the clinical and refractive outcomes of a modified Yamane technique for scleral fixation of the CT Lucia 602 lens. DESIGN: Retrospective case series. PATIENTS: One hundred twenty-one eyes with dislocated posterior chamber lens implants, surgical aphakia, subluxed crystalline lenses, capsular tear, anterior chamber, or iris sutured posterior chamber lens intolerance were included. METHODS: Secondary implantation of the Zeiss CT Lucia 602 lens was performed by a single surgeon using a modified Yamane technique employing a single needle, rather than the double-needle approach. One hundred twelve eyes underwent simultaneous 3 port pars plana vitrectomy and 9 eyes had previously undergone posterior vitrectomy surgery. Exclusion criteria were age <18, simultaneous glaucoma or corneal procedures, staged corneal transplantation, and follow-up <30 days. MAIN OUTCOME MEASURES: A paired t-test was used to compare pre- and post-operative corrected distance visual acuity (CDVA), the mean predictive error, and the mean absolute predictive error between the manufacturer's and optimized constants for Hoffer Q, Holladay I, and SRK/T. Complication rates were reported. RESULTS: One hundred twenty-one consecutive eyes with a mean follow-up of 237 days were included. The pre-operative CDVA was 0.871 ± 0.785 logMAR (mean ± standard deviation, Snellen equivalent 20/149), which improved to 0.401 ± 0.608 (Snellen equivalent 20/50) post-operatively. In 109 eyes with reliable postoperative refractions, the mean predictive refractive error (D) ± std was +0.74 ± 1.37 for Hoffer Q, +0.66 ± 1.41 for Holladay 1, and +0.47 ± 1.49 for SRK/T (p<0.05). Refractive outcome analysis yielded a mean optimized personalized anterior chamber depth (pACD) of 5.69, Surgeon Factor of 1.79, and A constant of 118.56. Vision-limiting complications occurred in 11 eyes (9.1%). CONCLUSION: Scleral fixation of the CT Lucia 602 lens using a single-needle modification of the Yamane technique resulted in very good visual acuity, predictable postoperative refractive errors, but some vision-limiting complications in this heterogeneous group of eyes with significant comorbidities.

Successful management of epithelial ingrowth after sequential intracameral 5-fluorouracil and Descemet-stripping automated endothelial keratoplasty.

To describe the successful treatment of epithelial ingrowth using combined surgical excision with intracameral adjuvant 5-fluorouracil (5-FU) followed by Descemet-stripping automated endothelial keratoplasty (DSAEK). A 71-year-old man presented with epithelial ingrowth after clear corneal phacoemulsification. He underwent surgical excision of the membrane together with pars plana vitrectomy, air fluid exchange, and intracameral 5-FU. This treatment resulted in corneal decompensation for which DSAEK was performed 6 months later. Despite interface haze, the postoperative corrected distance visual acuity returned to 20/40 three months after DSAEK. There was no clinical evidence of recurrence of the epithelial ingrowth 9 months after the surgical removal. Intracameral 5-FU can be used in conjunction with surgical excision and subsequent DSAEK to successfully treat epithelial ingrowth.

Removal of calcific band keratopathy without ethylenediaminetetraacetic acid (EDTA) in eyes with limited visual potential.

PURPOSE: Treatment of calcific band keratopathy (CBK) is commonly performed with ethylenediaminetetraacetic acid (EDTA), but EDTA has become more difficult to obtain. This paper describes a technique for treating CBK using a diamond-dusted burr without EDTA in eyes with limited visual potential. PATIENTS AND METHODS: In this paper, we provide detailed instructions on how to perform the surgical technique for treating CBK, along with a surgical video. We performed a retrospective review of consecutive patients with clinically significant CBK who underwent this procedure from December 2012 to July 2015. RESULTS: Seven eyes of six patients were included for analysis. Preoperatively, all patients suffered from ocular discomfort. All eyes had poor preoperative visual acuity due to non-corneal ocular disease. The most common causes of CBK in this series were retinopathy of prematurity (three eyes) and chronic uveitis (two eyes). Postoperatively, all patients reported partial or complete relief of discomfort. The length of follow-up ranged from 15 days to 31 months. Two eyes experienced recurrence of CBK. This occurred at 4 and 28 months after treatment. CONCLUSION: The diamond-dusted burr can easily and effectively remove the corneal epithelium and underlying calcium deposits. Therefore, it may be used to effectively treat discomfort from CBK.

Planned Descemetorhexis Without Endothelial Keratoplasty in Eyes With Fuchs Corneal Endothelial Dystrophy.

PURPOSE: The purpose of this study was to describe the results of a simple 6-mm central descemetorhexis in eyes with Fuchs corneal endothelial dystrophy. METHODS: This prospective nonrandomized IRB approved pilot study was performed on 2 patients with coexisting Fuchs dystrophy and cataract who underwent combined phacoemulsification and descemetorhexis without endothelial transplantation. RESULTS: In each patient, residual disciform stromal edema corresponded to the diameter of the descemetorhexis and led to an associated loss of visual acuity. Vision improved to 20/40 -1 in case 1 and to 150 -1 in case 2 during a follow-up period of 12 and 10 months, respectively. Endothelial cell repopulation of the descemetorhexis could not be confirmed because of the presence of persistent corneal edema. CONCLUSIONS: Because of the relatively poor postoperative visual acuity and slow visual recovery, a simple descemetorhexis is not an acceptable form of therapy for eyes with Fuchs corneal endothelial dystrophy.

Spontaneous Resolution of Acute Corneal Hydrops in a Patient With Post-LASIK Ectasia.

PURPOSE: To describe a case of acute corneal hydrops in a patient with corneal ectasia after laser in situ keratomileusis (LASIK). METHODS: An observational study presenting clinical, slit-lamp, and optical coherence tomographic findings. RESULTS: A 66-year-old man with a history of moderate myopic astigmatism presented with a sudden loss of vision in his left eye 11 years after undergoing LASIK. He underwent a single enhancement in his left eye and was subsequently diagnosed with ectasia 9 years later. Slit-lamp examination demonstrated a small tear in the Descemet membrane with a large fluid-filled cleft separating the LASIK flap and extending to the flap edge. Because no aqueous humor leakage was detected, the patient was managed conservatively with eventual resolution of the fluid-filled cleft and return of 20/30 visual acuity. CONCLUSIONS: Acute corneal hydrops is a rare complication of post-LASIK corneal ectasia. In the absence of flap dehiscence and wound leak, such patients may be managed with simple observation.

Long-term corneal clarity after spontaneous repair of an iatrogenic descemetorhexis in a patient with Fuchs dystrophy.

PURPOSE: To report a case of long-term corneal clarity after spontaneous resolution of corneal edema associated with iatrogenic endothelial trauma in a patient with Fuchs dystrophy. METHODS: Retrospective case report. RESULTS: An 84-year-old woman with Fuchs dystrophy experienced an iatrogenic descemetorhexis during complicated phacoemulsification. Despite marked early postoperative corneal edema, she experienced spontaneous clearing of her cornea within 4 months with eventual reendothelialization of the central defect. She maintained excellent visual acuity for 16 years with no evidence of recurrent corneal edema. CONCLUSIONS: Self-repair of a descemetorhexis and long-term corneal clarity may occur in eyes with underlying endothelial dystrophy.

Delayed massive suprachoroidal hemorrhage after descemet stripping automated endothelial keratoplasty.

PURPOSE: To report the development of a delayed massive suprachoroidal hemorrhage after Descemet stripping automated endothelial keratoplasty (DSAEK). DESIGN: Retrospective case report. RESULTS: A 70-year-old woman with a failed graft for keratoconus underwent DSAEK in the setting of continued systemic anticoagulation. On the first postoperative day, she experienced a massive suprachoroidal hemorrhage. Despite surgical drainage, the donor graft subsequently failed, and vision declined to light perception. CONCLUSIONS: Massive suprachoroidal hemorrhage may occur as a rare complication of DSAEK.

Intracameral bevacizumab administered for non-small cell lung cancer metastasis to iris.

Ocular iris metastasis from lung cancer is uncommon. We report a patient with metastatic non-small cell lung cancer who was found to have a metastatic lesion to the iris. Local therapy for pain control and vision loss was administered with intracameral bevacizumab. Complete resolution of pain, improvement in vision, and near complete resolution of iris tumor were seen within two months. No ocular toxicity to anterior segment structures was detectable on corneal pachymetry and corneal specular microscopy. This is the first case report demonstrating safety and efficacy of intracameral bevacizumab for iris metastasis from non-small cell lung cancer.

A simple technique to improve centration during trephination of the donor lenticula in DSAEK.

The author describes a technique to improve centration of the trephination of the donor corneal lenticula during Descemet's stripping and automated endothelial keratoplasty. Following resection of the anterior corneal lamella with the microkeratome, a 10-mm trephine stained with gentian-violet dye is used to mark the perimeter of the resection bed. The remaining donor cornea is centered on the Barron-Hessburg punching block endothelial side up using the easily seen annular mark as a guide. Using this technique, the author has successfully avoided eccentrically trephined donor lenticulae in cases. This simple technique allows the surgeon performing Descemet's stripping and automated endothelial keratoplasty to consistently punch the donor lenticula within the margins of the anterior lamellar resection.

Descemet stripping automated endothelial keratoplasty in the phakic eye.

PURPOSE: To evaluate the visual acuity, graft clarity, refractive outcome, and crystalline lens clarity in phakic patients undergoing Descemet stripping automated endothelial keratoplasty (DSAEK). METHODS: Six eyes of 4 consecutive patients with clear crystalline lenses and corneal edema because of either Fuchs dystrophy (4 eyes) or amantadine-induced corneal endothelial toxicity (2 eyes) were included in this study. All patients underwent simple DSAEK using a 4.2-mm temporal clear corneal incision. The 8.5-mm donor lenticule was folded and inserted into the anterior chamber using an Utrata forceps. A 10-minute air bubble tamponade was used. RESULTS: Best-corrected spectacle visual acuity, refractive error, graft status, and crystalline lens clarity were measured at a minimum of 6 months postoperatively. All grafts for Fuchs dystrophy remained clear, whereas 2 grafts failed because of continued amantadine corneal toxicity. Excluding the failed grafts, the average preoperative best-corrected spectacle visual acuity was 20/47 compared with 20/28 postoperatively (P = 0.0024). There were no intraoperative complications, and no eyes developed pupillary block glaucoma or cataracts during an average follow-up interval of 9.1 months (6-14 months). CONCLUSION: DSAEK may be safely performed in the phakic eye.

Corneal sensation after descemet stripping and automated endothelial keratoplasty.

PURPOSE: To measure corneal sensation after Descemet stripping and automated endothelial keratoplasty (DSAEK). METHODS: Prospective comparative case series involving 52 eyes of 29 patients in the early postoperative period (<6 months) after small-incision DSAEK. Patients' contralateral eye served as a control. The sample size calculation was calculated assuming an alpha error of 0.05 and a beta error of 0.2. This determined that a sample size of 11 patients would be sufficient to detect a difference in corneal sensation of 5 mm as measured with the Cochet-Bonnet esthesiometer. The nylon filament was used to measure threshold sensation at 9 points on the operative eye and 5 points on the control. The data were analyzed using the paired samples test. RESULTS: Although the results demonstrated mild hypesthesia of the corneal epithelium overlying the donor lenticule, we found no statistically significant difference in corneal sensation at the central point when comparing the DSAEK cornea with the control (57 vs 59 mm, P = 0.13.) In addition, when comparing corresponding points on the epithelium overlying the DSAEK graft and host cornea, no significant difference was found (57 vs 58 mm, P = 0.32). A difference was detected when comparing the average corneal sensation of the DSAEK eye with the control, but careful analysis of the data shows that this was driven by the slight decrease in sensitivity at the temporal incisional point (57 vs 59 mm, P = 0.002). CONCLUSIONS: The results of this prospective study demonstrate the relative preservation of corneal sensitivity after DSAEK. Preservation of corneal sensation may provide another advantage of DSAEK over traditional penetrating keratoplasty.

Intraocular lens power selection in the second eye of patients undergoing bilateral, sequential cataract extraction.

PURPOSE: To determine if the 1-month postoperative error of predicted refraction of the first eye can be used to alter intraocular lens (IOL) power selection and improve refractive results for the second eye in patients undergoing bilateral, sequential phacoemulsification with IOL implantation (phaco/IOL). DESIGN: Retrospective, consecutive, case series. PARTICIPANTS: Three hundred consecutive patients who underwent uncomplicated bilateral, sequential phaco/IOL between January 1, 2006, and December 31, 2007, by a single surgeon using a single IOL platform. METHODS: The observed second eye 1-month postoperative spherical equivalent refractive error was compared with calculations of the hypothetic 1-month postoperative spherical equivalent refractive error if the first eye error had been fully or partially incorporated into the choice of IOL power for the second eye. The optimal amount of partial adjustment was determined. MAIN OUTCOME MEASURES: The error of predicted refraction: the difference between the actual or hypothetic spherical equivalent refractive errors and those predicted by preoperative calculations. RESULTS: A total of 206 patients met inclusion criteria. The average of the absolute value of the unadjusted second eye error (|E(UNADJ)|) was +0.44 diopters (D) compared with +0.42 D for the fully adjusted second eye error (|E(FULL)|). The optimal amount of adjustment of the second eye IOL power was determined to be 50%; the average of the absolute value of this partially adjusted second eye error (|E(PARTIAL,50%)|) was +0.36 D; this was statistically different from |E(UNADJ)| (P<0.0001) and |E(FULL)| (P = 0.001). The statistically significant benefit was observed for patients with either myopic or hyperopic errors in the first eye. The percentages of patients achieving postoperative refractions within 0.5 D and 1.0 D of the predicted refraction were 66.5% and 90.3%, respectively, for the unadjusted second eye, 67.0% and 90.8%, respectively, for the hypothetic fully adjusted second eye, and 74.3% and 93.7%, respectively, for the hypothetic partially adjusted (50%) second eye. CONCLUSIONS: Accounting for 50% of the observed error of predicted refraction of the first eye reduced the error of predicted refraction in the second eye. This novel methodology has the potential to improve the refractive outcomes in the second eye of patients with cataract. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Nonimmunologic graft failure after Descemet's Stripping Automated Endothelial Keratoplasty (DSAEK) for presumed amantadine-induced corneal edema.

CONTEXT: With one exception, a case report of amantadine-induced corneal toxicity has described reversible corneal edema. OBJECTIVE: To report a patient with unrecognized amantadine-induced corneal edema. DESIGN: Patient with schizophrenia and tardive dyskinesia developed bilateral corneal edema while receiving chronic amantadine hydrochloride. Both eyes underwent successful phakic Descemet's stripping automated endothelial keratoplasty, and histopathologic examination of the excised host tissue was performed. RESULTS: Despite initial clearing of the donor lenticules, both eyes later experienced nonimmunologic graft failure, probably related to continued amantadine corneal toxicity. After discontinuation of the amantadine, one graft demonstrated partial clearing. Histopathology demonstrated endothelial cell loss. Specular microscopy demonstrated pleomorphism and disruption of the orderly hexagonal array. CONCLUSIONS: Chronic amantadine hydrochloride therapy may be responsible for irreversible corneal edema and may lead to graft failure in unrecognized cases.

Candida keratitis after descemet stripping and automated endothelial keratoplasty.

PURPOSE: To report the donor-to-host transmission of Candida albicans after Descemet stripping and automated endothelial keratoplasty (DSAEK). METHODS: An 80-year-old woman with pseudophakic bullous keratopathy developed an infiltrate in the donor corneal lenticule after DSAEK. RESULTS: Donor corneoscleral rim cultures grew C. albicans. Gram stain of the removed corneal lenticule demonstrated budding yeast and pseudohyphae, and cultures yielded C. albicans. Despite topical and systemic antifungal therapy and therapeutic penetrating keratoplasty, the patient developed a blind painful eye and underwent enucleation. CONCLUSIONS: This case report indicates that fungal keratitis may occur from donor-to-host transmission after DSAEK. The location of the infected tissue poses diagnostic and therapeutic challenges for the surgeon.

External refinement of the donor lenticule position during descemet's stripping and automated endothelial keratoplasty.

The authors describe a technique to facilitate the centration of the donor lenticule during Descemet's stripping and automated endothelial keratoplasty. The donor corneal lenticule is unfolded and grossly centered in the anterior chamber using a barbed 30-gauge needle on a 3-cc air syringe or a reverse Sinsky hook. Fine adjustments to center the lenticule can be achieved by applying external pressure to the cornea with a laser in-situ keratomileusis flap roller. This simple technique provides a mechanism for simultaneously removing interface fluid and allows the surgeon to center the donor corneal lenticule without further risk of direct mechanical trauma to the donor endothelium.

Bilateral recurrent self-induced keratoconus.

The observational case describes bilateral recurrent keratoconus in corneal transplants performed in a patient with self-induced keratoconus secondary to compulsive eye rubbing. Slitlamp findings demonstrated corneal stromal thinning and scarring in the patient's right eye and temporal corneal hydrops in his left eye. Videokeratography of the right eye confirmed the presence of corneal steepening and irregular astigmatism, consistent with the diagnosis of keratoconus involving each transplant. Together with the history of ongoing compulsive eye rubbing, these findings support the concept that chronic mechanical trauma to the cornea may contribute to the development of keratoconus.

Epithelial ingrowth after Descemet-stripping automated endothelial keratoplasty.

PURPOSE: To report the diagnosis and treatment of a patient who developed epithelial ingrowth after Descemet-stripping automated endothelial keratoplasty (DSAEK). METHODS: We describe the case of an 80-year-old woman who underwent DSAEK for pseudophakic bullous keratopathy. After surgery, the patient underwent 2 additional rebubbling procedures for recurrent donor lenticule dislocation. She was subsequently found to have an enlarging interface epithelial ingrowth that led to graft failure. RESULTS: After donor lenticule exchange, mechanical scraping, and irrigation-aspiration of residual epithelial cells, there was no evidence of the histologically confirmed epithelial ingrowth during a 2-year follow-up interval. CONCLUSIONS: This 1 case report suggests that epithelial ingrowth may occur after DSAEK. This case was successfully treated surgically.

Visual acuity, refractive error, and endothelial cell density six months after Descemet stripping and automated endothelial keratoplasty (DSAEK).

PURPOSE: To evaluate visual acuity, refractive outcomes, and endothelial cell density 6 months after Descemet stripping and automated endothelial keratoplasty (DSAEK). METHODS: We performed an institutional review board-approved prospective study of a surgical case series of 34 patients at 2 institutions undergoing DSAEK for Fuchs endothelial dystrophy, pseudophakic bullous keratopathy, or aphakic bullous keratopathy with or without simultaneous phacoemulsification and intraocular lens implantation. Clinical outcomes, including best spectacle-corrected visual acuity (BSCVA), spherical equivalent refraction, and refractive astigmatism and topographic or keratometric astigmatism, were assessed at the 6-month postoperative examination and compared with preoperative values with paired Student t tests. The change in endothelial cell density from the eye bank examination to 6 months after transplantation was similarly evaluated. RESULTS: BSCVA averaged 20/99 preoperatively and 20/42 postoperatively (P < 0.0001). After DSAEK, 30 (88.2%) of 34 patients showed improved BSCVA, and 21 (61.8%) of the 34 patients achieved a BSCVA of 20/40 or better. For patients not undergoing simultaneous phacoemulsification and intraocular lens implantation, a hyperopic shift in refraction of 1.19 +/- 1.32 D was noted. Refractive astigmatism, topographic astigmatism, and keratometry showed no statistically significant change. Endothelial cell density of donor corneas averaged 2826 +/- 370 cells/mm, whereas the mean postoperative density was 1396 +/- 440 cells/mm. This finding corresponded to an average loss of 1426 cells/mm (50% loss; P = 0.0001). The first half of cases experienced an average cell loss of 1674 cells/mm (59% loss) compared with 1181 (41% loss) in the second half of cases (P = 0.005). Three (9%) of 34 grafts experienced iatrogenic graft failure and required reoperation with new donor tissue. Also, 9 (27%) of 34 grafts experienced dislocation in the early postoperative period and required repositioning. CONCLUSIONS: In this prospective study of DSAEK for bullous keratopathy and Fuchs endothelial corneal dystrophy, improvement of visual acuity was achieved with only a mild tendency toward hyperopic shift and without significant induced astigmatism. Endothelial cell loss was significant, however, and may be related to surgical experience.