Allogeneic Ocular Surface Stem Cell Transplantation Outcomes With Decreased or No Systemic Immunosuppression in the Elderly.

PURPOSE: The aim of this study was to report outcomes after allogeneic ocular surface stem cell transplantation (OSST) for limbal stem cell deficiency in the setting of decreased or no systemic immunosuppression (SI) in the elderly. METHODS: A retrospective chart review was performed of all eyes that underwent OSST for limbal stem cell deficiency between 2005 and 2020 at CVP Physicians. Inclusion criteria included patients who were (1) at least 70 years at the time of (2) allogeneic OSST. Postoperative SI regimens were assessed. Outcome measures included improvement in visual acuity, ocular surface stability, and adverse effects. RESULTS: There were 14 eyes of 14 patients that met the inclusion criteria with mean follow-up of 3.0 (range 0.4-7.0) years. SI was run at a lower level for 6 patients, and 8 patients did not receive any SI. Nine eyes underwent keratolimbal allograft, 1 had a living-related conjunctival limbal allograft, and 4 had combined OSST. Most eyes (85.7%) attained improvement in visual acuity during their follow-up. At the last follow-up, 57.1% maintained a stable ocular surface. Six eyes developed acute rejection or late failure. Minimal adverse events were noted. CONCLUSIONS: Elderly patients administered less or no SI exhibit overall favorable outcomes after allogeneic OSST. Although not significantly different, surface stability and duration of improved vision was greater with low SI. No SI may be an option that still achieves improved vision in a high proportion for at least part of their follow-up. Decreasing SI after OSST in this population can improve quality of life while minimizing adverse effects.

Presence of Panel-reactive Antibodies after Penetrating Keratoplasty.

PURPOSE: To evaluate the relationship between penetrating keratoplasty (PK) and postoperative PRA level and number of unacceptable antigens. METHODS: A cross-sectionalstudy was performed on patients with history of PK. Patients with prior solid organ transplantation, pregnancy, or blood transfusion were excluded. These findings were combined with a retrospective review. Patients were grouped by single or multiple PKs. The primary outcome was postoperative PRA level. RESULTS: Incidence of postoperative PRA elevation and mean peak PRA was higher in the multiple PK group (p = .08 and p = .010, respectively). Mean number of unacceptable antigens was elevated in the multiple PK group (p = .024). There was a moderately positive correlation between number of PK grafts and PRA level (r = 0.629, p = .0002). CONCLUSIONS: PRA level may be influenced by PKs, with higher PRA associated with increased prior PKs. Further studies are necessary to determine the potential prognostic value.Abbreviations: PK: penetrating keratoplasty; PRA: panel reactive antibodies; OSST: ocular surface stem cell transplantation; LSCD: limbal stem cell deficiency.

Use of Cenegermin in the Presence of Bandage Contact Lenses.

PURPOSE: The aim of this study was to characterize the outcomes of eyes with neurotrophic keratitis (NK) treated with a course of cenegermin-bkbj in the presence of a bandage contact lens (BCL). METHODS: A retrospective chart review of all eyes with a clinical diagnosis of NK treated with cenegermin-bkbj was performed between 2018 and 2020. Inclusion criteria included cenegermin-bkbj treatment with a BCL in place. Demographics, etiology, visual acuity, pretreatment and posttreatment corneal sensation, and treatment outcomes were assessed. RESULTS: There were 18 eyes of 16 patients (69% female) with NK treated with cenegermin-bkbj while having a BCL in place. After cenegermin-bkbj treatment, presence of corneal sensation significantly increased from 7% of eyes to 79% of eyes (P < 0.0001). There was also a significant increase in the number of quadrants with corneal sensation (mean of 0.1 quadrants increased to 1.6 quadrants, P =0.0005). Six of 10 eyes (67%; P = 0.004) with a persistent epithelial defect (PED) experienced complete resolution at the conclusion of treatment, while 3 additional eyes experienced a decrease in the defect size. Despite all 18 eyes necessitating a chronic BCL before cenegermin-bkbj treatment, 4 were able to maintain their epithelium without a BCL after treatment for at least some period. CONCLUSIONS: Cenegermin-bkbj treatment for NK with a BCL in place demonstrated improvement in corneal sensation, epithelial defect size, and fluorescein staining. In eyes demonstrating previous ocular surface decompensation with discontinuation of a BCL, maintenance of BCL use during treatment with cenegermin-bkbj may be considered.

Limbal Stem Cell Deficiency: Demographics and Clinical Characteristics of a Large Retrospective Series at a Single Tertiary Referral Center.

PURPOSE: The aim of this study was to characterize a large cohort of patients presenting to a single referral center for limbal stem cell deficiency (LSCD). METHODS: A retrospective chart review of all patients with a clinical diagnosis of LSCD from 2002 to 2015 was performed. Demographics, etiology, previous ocular surgeries, visual acuity, and treatment were assessed. RESULTS: Seven hundred thirty-eight eyes of 434 patients (51.4% male subjects) were diagnosed with LSCD. The mean presenting age was 42.9 years, 70% presented with bilateral disease, and overall vision was poor. The most common etiologies were congenital aniridia (30.9%), chemical or thermal injuries (20.6%), contact lens (16.8%), Stevens-Johnson syndrome (SJS, 10.4%), and iatrogenic (7.3%). Congenital aniridia had a significantly increased association with glaucoma or ocular hypertension (P < 0.0001). Chemical or thermal injuries (P = 0.0007), SJS (P < 0.0001), and mucous membrane pemphigoid (P < 0.0001) had a significantly increased association with eyelid pathology. The mean logMAR best corrected visual acuity (analysis excluded eyes with light perception and no light perception) at presentation was 1.145 (∼20/280). Keratoplasty performed (before presentation at our center) without first addressing the LSCD was seen in 80 eyes; all keratoplasties failed due to recurrence of the LSCD. CONCLUSIONS: Patients presenting with LSCD were on average middle aged without sex predominance. LSCD was most commonly bilateral, comprised a wide range of etiologies, and decreased vision substantially. Ocular comorbidities may need to be treated before treating the LSCD surgically. Finally, not addressing the LSCD (primary issue) first can result in keratoplasty failure.

Use of Panel-Reactive Antibody Testing in the Planning and Management of Ocular Surface Stem Cell Transplantation.

PURPOSE: Panel-reactive antibody (PRA) testing has been widely adopted in solid organ transplantation for risk assessment in potential allograft recipients but has not been studied in the context of ophthalmic transplantation. The purpose of this study is to evaluate outcomes in patients undergoing ocular surface stem cell transplantation (OSST) for limbal stem cell deficiency (LSCD) relative to preoperative PRA level. METHODS: This is retrospective chart review of all eyes with documented PRA level that underwent OSST for LSCD between May 2000 and March 2019 at a single institution. Eyes with stable ocular surface but <1 year of follow-up and eyes without updated PRA before repeat OSST were excluded. Eyes were grouped by PRA <80% and ≥80%. The primary outcome was ocular surface failure, whereas the secondary outcome was clinical allograft rejection. RESULTS: Sixty-nine surgeries met inclusion criteria, consisting of 54 living-related conjunctival limbal allografts, 5 keratolimbal allografts, and 10 combined living-related conjunctival limbal allografts/keratolimbal allografts (Cincinnati procedure). The most common etiologies for LSCD were aniridia (33%), chemical/thermal injury (28%), and contact lens associated (14%). Surface failure occurred in 5 of 12 eyes (58%) with PRA ≥80% versus 12 of 57 eyes (21%) with PRA <80% (P = 0.01). The relative risk for surface failure with PRA ≥80% was 2.8 [confidence interval (CI), 1.38-5.55]. There was no significant difference in acute rejection (P = 1). CONCLUSIONS: Pretransplant PRA level is an important prognostic factor for ocular surface stability in eyes undergoing OSST for LSCD, with implications for donor selection, perioperative management, and systemic immunosuppression.

PARACENTRAL ACUTE MIDDLE MACULOPATHY ASSOCIATED WITH IDIOPATHIC INTRACRANIAL HYPERTENSION.

PURPOSE: Paracentral acute middle maculopathy (PAMM) is a recently identified clinical entity with numerous retinal vascular and systemic associations. To our knowledge, this is the first reported case of PAMM associated with idiopathic intracranial hypertension. METHODS: A case is presented with multimodal imaging. RESULTS: A patient with idiopathic intracranial hypertension is found to have the characteristic clinical, spectral domain optical coherence tomography, and OCT angiography findings associated with PAMM. CONCLUSION: Paracentral acute middle maculopathy is believed to arise from a microvascular insult to the retinal deep capillary plexus. We add a previously undescribed association with idiopathic intracranial hypertension to the list of etiologies that can cause PAMM.

Comparison of Glaucoma Drainage Device Versus Transscleral Cyclophotocoagulation for Secondary Glaucoma Following Ocular Surface Stem Cell Transplantation.

PRCIS: Rates of ocular surface failure and glaucoma reoperation were similar between cyclophotocoagulation (CPC) and glaucoma drainage devices (GDDs). CPC is a safe option in the management of secondary glaucoma after ocular surface stem cell transplantation (OSST). PURPOSE: To assess surgical and ocular surface outcomes in patients requiring glaucoma surgery after OSST. MATERIALS AND METHODS: Retrospective chart review of eyes with previous OSST that underwent either transscleral CPC or implantation of a GDD. Primary outcomes were ocular surface failure (defined as recurrence of corneal conjunctivalization with late fluorescein staining) and glaucoma surgery failure (defined as the need for additional glaucoma surgery, including repeat treatment or revision). Secondary outcomes were changes in intraocular pressure (IOP) and number of glaucoma medications. Additional subgroup analysis was performed for subtypes of CPC and GDD. RESULTS: Thirty-six glaucoma surgeries (7 Ahmed, 19 Baerveldt, and 10 CPC) were performed in 31 eyes with a history of prior OSST. The ocular surface failure rate was 19% for GDDs and 10% for CPC (P=0.65). Additional glaucoma surgery was needed for 38% of GDDs and 70% of CPC (P=0.14). The mean IOP reduction was 50% for GDDs and 28% for CPC (P=0.05). The mean drop reduction was 1.6 for GDDs and 0.1 for CPC (P=0.02). All glaucoma failures in the GDD group were related to tube erosion and/or hypotony, whereas all glaucoma failures in the CPC group were because of uncontrolled IOP. There were no significant differences in primary or secondary outcomes between CPC or GDD subgroups. CONCLUSION: Glaucoma is a frequent comorbidity in patients with severe ocular surface disease, and treatment poses unique challenges in those with prior OSST. In this study, ocular surface failure and glaucoma reoperation rates were similar between CPC and GDD groups, suggesting that CPC, including repeat treatment, is a safe option for the management of secondary glaucoma after OSST. A multidisciplinary approach is recommended in the management of these complex eyes.

"Basket" mattress suture to manage positive vitreous pressure during penetrating keratoplasty.

OBJECTIVE: To describe a new/modified technique to manage posterior vitreous pressure (PVP) during penetrating keratoplasty (PKP) and report a small series. DESIGN: Retrospective interventional case series and technique description. PARTICIPANTS: PKP eyes necessitating mattress suture placement owing to PVP. METHODS: Retrospective chart review from 2016 to 2019 was undertaken. Placed prophylactically (before trephination) or after trephination, the mattress suture is placed limbus-to-limbus across the anterior chamber. A second mattress suture can be placed in the opposite meridian (perpendicularly) for added support (safety basket configuration). Variations of suture technique are described based on lens status (i.e., phakic, pseudophakic, aphakic) and intraoperative timing. Parameters assessed included demographics, lens status, suture indications, intraoperative technique details, successful PKP completion, and presence of primary failure. RESULTS: There were 6 phakic eyes (5 patients) and 9 pseudophakic/aphakic eyes (8 patients). Indications for the phakic subgroup were obesity (83%), poor scleral rigidity (83%), repeated iris prolapse (67%), dense mature cataract (33%), and planned large-diameter PKP (33%). Indications for pseudophakic/aphakic eyes included intraocular lens/iris prolapse (100%), pre-existing iris defects (67%), and planned large-diameter PKP (33%). Successful PKP was performed in all cases. Whereas one case had residual corneal edema in the setting of a persistent epithelial defect owing to limbal stem cell deficiency, all other cases demonstrated no primary graft failure. CONCLUSIONS: Although increased PVP can present a stressful and challenging situation, it is important to have multiple options for management. This simple mattress suture technique normalizes the lens-iris complex behaviour and appears safe for the donor graft.

Crystalline Lens Resorption Caused by Ciliary Body Melanoma.

We report a case of a 51-year-old Caucasian female who presented with a ciliary body melanoma of the right eye leading to focal resorption of the crystalline lens and inducing posterior subcapsular cataract. She underwent successful enucleation, and histopathology demonstrated a ciliary body melanoma with a predominance of epithelioid cells and focal scleral extension. Genetic testing revealed a heterozygous, pathogenic mutation of BAP1 (c.1717delC, p.Leu573fs). Crystalline lens resorption is a rare but potentially important finding in ciliary body melanoma, as early detection of malignancy can be lifesaving.

Surgical Cystotomy of a Large Iris Pigment Epithelial Cyst with Microinstrumentation.

PURPOSE: Surgical intervention is indicated for large primary iris pigment epithelial cysts that significantly affect vision or compromise adjacent structures. Methods described in the literature include laser photocoagulation, needle aspiration, and complete resection. METHODS: We describe a novel surgical technique in which a surgical cystotomy is created for a large, symptomatic iris pigment epithelial cyst using microsurgical instruments for a patient in whom needle aspiration was unsuccessful. RESULTS: The patient's visual symptoms had largely resolved within 1 week postoperatively, no complications were encountered, and there was no clinical or sonographic evidence of cyst recurrence after 14 months. CONCLUSION: Surgical cystotomy with microinstrumentation may be an effective tool for management of primary iris pigment epithelial cysts, especially as an alternative after needle aspiration fails.