Association Between Indication for Descemet Stripping Automated Endothelial Keratoplasty and Rural Residency.

PURPOSE: Residing in rural locations can be a barrier to health care access. This study investigated the impact of residing in rural and small town (RST) areas on Descemet stripping automated endothelial keratoplasty (DSAEK) indications and outcomes in Atlantic Canada. METHODS: A retrospective cohort analysis examined consecutive DSAEKs performed in Nova Scotia between 2017 and 2020. Patient rurality was determined by the Statistical Area Classification system developed by Statistics Canada. Univariate and multivariate logistic regression models were used to assess for factors associated with DSAEK indication, including repeat keratoplasty, RST residence status, and travel time. RESULTS: Of 271 DSAEKs during the study period, 87 (32.1%) were performed on the eyes of RST residents. The median postoperative follow-up time was 1.6 years. Undergoing DSAEK for a previous failed keratoplasty was not associated with a higher odds of RST residency (odds ratio [OR], 0.50; 95% confidence interval [CI], 0.19-1.16; P = 0.13) but was associated with travel time (OR, 0.78 for each increasing hour of travel; 95% CI, 0.61-0.99; P = 0.044). RST residency was not associated with the occurrence of graft failure (OR, 0.48; 95% CI, 0.17-1.17; P = 0.13). CONCLUSIONS: Residing in a rural area in Atlantic Canada was not associated with DSAEK graft failure. Repeat endothelial keratoplasty was associated with shorter travel time for corneal surgery but not rural residency status. Further research in this field could inform regional health strategies aimed at improving equity and accessibility to ophthalmology subspecialist care.

Graft dislocation following Descemet stripping automated endothelial keratoplasty: a comparative cohort analysis of Optisol GS and organ culture preserved corneas.

Previous studies have suggested risk factors for graft dislocation after Descemet stripping automated endothelial keratoplasty (DSAEK). We aimed to investigate the influence of eye bank storage solution as a risk factor for graft dislocation, as this could have significant implications for eye banking practices. This retrospective analysis compared cohorts from the QEII Health Sciences Center, Halifax, Canada (donor corneas preserved in Optisol GS) and the Royal Victorian Eye and Ear Hospital, Melbourne, Australia (donor corneas preserved in organ culture). Patient, surgical, and post-operative data were collected for consecutive DSAEK surgeries performed between 2012 and 2020. Risk factors were analyzed using univariate and multivariate logistic regression modeling. 654 DSAEK surgeries were performed during the study period: 271 in the Optisol GS storage cohort and 383 in the organ culture cohort. The most common indications were pseudophakic bullous keratopathy, Fuchs endothelial dystrophy, and failed previous DSAEK. The incidence of graft dislocation requiring surgical repositioning was 9.6% (n = 26) in the Optisol GS cohort and 12.0% (n = 46) in the organ culture cohort (OR, 0.50, 95% CI, 0.20-1.13). Development of graft dislocation was associated with intraoperative venting incisions (OR, 2.50, 95% CI, 1.12-5.51) and a post-operative wound leak (OR, 55.24, 95% CI, 10.20-514.85). The incidence of DSAEK dislocation was similar between study sites using Optisol GS and organ culture, suggesting changes in eye bank storage solution would not mitigate this post-operative complication. Intraoperative creation of venting incisions and post-operative wound leaks and were factors associated with graft dislocation.

Structural integrity of intraocular lenses with eyelets in a model of transscleral fixation with the Gore-Tex suture.

PURPOSE: To compare fracture characteristics of intraocular lenses (IOLs) used in transscleral fixation with the Gore-Tex suture. SETTING: Department of Ophthalmology and Visual Sciences, Dalhousie University, Halifax, Nova Scotia, Canada. DESIGN: Experimental study. METHODS: A model was designed to compare the eyelet fracture characteristics of enVista MX60 IOL (model available before June 2018), the enVista MX60E IOL (current model), the Akreos AO60 IOL, and the CZ70BD IOL. Tension was applied through the Gore-Tex suture and measured with a digital force gauge. Two suture configurations (radial and nonradial) were tested using the MX60E IOL. RESULTS: A total of 25 trials were conducted. The mean eyelet fracture force was 1.666 newtons (N) for the MX60 IOL (range, 1.000-2.000), 1.000 N for the MX60E IOL (range, 1.000-1.000), 2.330 N for the AO60 IOL (range, 2.000-3.000), and 0.998 N for the CZ70BD IOL (range, 0.990-1.000). When compared with the MX60E IOL, a greater eyelet strength was observed with the MX60 (P = .024) and AO60 (P = .004) IOLs. Radial and nonradial suture configurations did not affect the MX60E eyelet fracture force. CONCLUSIONS: The enVista MX60E eyelet may be less resistant to Gore-Tex suture tear out compared with the MX60 and AO60 IOLs. Altering suture configuration did not affect enVista eyelet resistance to fracture. During off-label use in transscleral fixation, extra caution should be taken when handling IOLs and applying tension on sutures.

Peripheral Ulcerative Keratitis Secondary to Atypical Hemolytic Uremic Syndrome.

PURPOSE: To report a case of peripheral ulcerative keratitis secondary to atypical hemolytic uremic syndrome. METHODS: We report the case of a 76-year-old man who presented with bilateral aggressive peripheral ulcerative keratitis. Clinical examinations and investigations are reported from the patients' admission. RESULTS: The patient had an extended workup for autoimmune and infectious etiologies that all returned negative. The laboratory work in conjunction with renal biopsy and clinical symptoms were consistent with atypical hemolytic uremic syndrome. The patient was treated with systemic steroids for his peripheral ulcerative keratitis and underlying systemic disease. Corneal glueing and amniotic membrane grafting was also performed. CONCLUSIONS: To our knowledge, we report the first known case of peripheral ulcerative keratitis secondary to atypical hemolytic uremic syndrome. In cases where the standard workup is negative, this diagnosis should be considered because it can have significant systemic morbidity.

MASSIVE SUBRETINAL GAS AFTER VITRECTOMY SURGERY: MECHANISM AND MANAGEMENT.

PURPOSE: To describe the complication of subretinal gas after pars plana vitrectomy for rhegmatogenous retinal detachment, as well as its management. METHODS: The presence of subretinal gas was noted on postoperative Day 1 after pars plana vitrectomy for a chronic rhegmatogenous retinal detachment. Resolution of subretinal gas was facilitated by an infusion line and external sclerotomy to expand the vitreous cavity. Residual subretinal gas was removed through a posterior retinotomy after fluid-air exchange. RESULTS: This technique resulted in the successful evacuation of subretinal gas, allowing for chorioretinal adhesion and reattachment of the retina. CONCLUSION: Subretinal gas can rarely occur after pars plana vitrectomy for rhegmatogenous retinal detachment. This complication can be successfully managed by way of external drainage, followed by evacuation of residual gas through fluid-air exchange and posterior retinotomy.

Bilateral HPV Positive Squamous Cell Carcinoma In Situ of Conjunctiva.

A 45 year-old woman presented with blurred vision and irritation of the left eye. Clinical examination revealed a superior palpebral conjunctival lesion consistent with a diagnosis of papilloma. She was lost to follow up despite repeated attempts to schedule a biopsy, and presented again after an extended period with bilateral disease. Subsequent biopsy confirmed bilateral squamous cell carcinoma in situ which was human papilloma virus-16 positive by molecular testing. She declined further treatment; during the subsequent year, the lesions extended across the bulbar conjunctiva bilaterally.

Recurrence of Granular Corneal Dystrophy Type 1 After Phototherapeutic Keratectomy, Lamellar Keratoplasty, and Penetrating Keratoplasty in a Single Population.

PURPOSE: To describe the recurrence of granular corneal dystrophy type 1 (GCD1) after penetrating keratoplasty (PKP), anterior lamellar keratoplasty (ALK), deep anterior lamellar keratoplasty (DALK), and phototherapeutic keratectomy (PTK) in a single population. The time required to achieve best-corrected visual acuity (BCVA) after each intervention was also analyzed. METHODS: Retrospective review of all patients with GCD1 from a single center between 1989 and 2016. Surgical interventions were performed 50 times on 28 eyes of 15 patients. Data were primarily analyzed through Cox regression modeling with clustering and robust log-rank testing. RESULTS: Significant recurrence occurred most rapidly after PTK (median time 2.7 years) and was most delayed after PKP (13.7 years). Significant recurrence occurred at a similar interval after ALK and DALK (3.7 and 3.2 years, respectively). Significant recurrence-free survival was longer for PKP than for ALK, DALK, or PTK (P = 0.04). The time required to obtain BCVA was shorter in the PTK group (median 1.8 months) than in the PKP and DALK groups (median 5.3 and 8.4 months, respectively; P = 0.03 and P = 0.02). All groups achieved a similar median BCVA (20/25-20/30). CONCLUSIONS: This series indicates that GCD1 recurrence-free survival is longest after PKP with an associated delay in attaining BCVA. Conversely, PTK provided the fastest visual recovery with shorter recurrence-free survival.

VEGF-A is increased in exogenous endophthalmitis.

OBJECTIVE: Exogenous endophthalmitis is an ophthalmologic emergency defined by panocular inflammation. Vascular endothelial growth factor A (VEGF-A) contributes to inflammation by promoting chemotaxis of monocytes and granulocytes and by increasing vascular permeability. The purpose of this article is to determine if VEGF-A is elevated in the vitreous samples obtained from individuals with exogenous endophthalmitis. METHODS: Vitreous samples from individuals with exogenous endophthalmitis (n = 18) were analyzed via Luminex assay and enzyme-linked immunosorbent assay for the cytokines VEGF-A, tumor necrosis factor (TNF), interleukin 6 (IL-6), IL-8 (chemokine [CXCL]-8), IL-1ß, IL-10, IL-12p70, IL-33, interferon (IFN)-γ, IFN-α, IFN-ß, chemokine ligand (CCL)-3, IL-2, IL-5, IL-15, CXCL-10, CCL-2, IL-1Ra, CCL-5, IL-17, and CCL-11. Vitreous samples obtained at the time of macular hole surgery served as controls (n = 8). RESULTS: Concentrations of VEGF-A were significantly elevated in vitreous samples from individuals with exogenous endophthalmitis compared with macular hole (p < 0.001). VEGF-A was significantly upregulated in individuals with exogenous endophthalmitis after cataract surgery (p = 0.001), vitrectomy (p = 0.024), and intravitreal injection (p = 0.012). VEGF-A concentrations were similar in both culture-positive and culture-negative populations (p > 0.05). In a linear regression model, levels of VEGF-A correlated significantly with the chemokine CXCL-8 (p = 0.028). CONCLUSIONS: We demonstrate that VEGF-A is potently upregulated in exogenous endophthalmitis. This observation provides a foundation for future studies of targeted VEGF-A blockade in the management of endophthalmitis.

The negative predictive value of ultrasound-guided 14-gauge core needle biopsy of breast masses: a validation study of 339 cases.

PURPOSE: To determine the negative predictive value of sonographically guided 14-gauge core needle biopsy of breast masses, with detailed analysis of any false-negative cases. MATERIALS AND METHODS: We reviewed 669 cases of sonographically guided 14-gauge core needle biopsies that had benign pathologic findings. Given a benign pathology on core biopsy, true-negatives had either benign pathology on surgical excision or at least 2 years of stable imaging and/or clinical follow-up; false-negatives had malignant histology on surgical excision. RESULTS: Follow-up was available for 339 breast lesions; 117 were confirmed to be benign via surgical excision, and 220 were stable after 2 years or more of imaging or clinical follow-up (mean follow-up time 33.1 months, range 24-64 months). The negative predictive value was determined to be 99.4%. There were 2 false-negative cases, giving a false-negative rate of 0.1%. There was no delay in diagnosis in either case because the radiologist noted discordance between imaging and core biopsy pathology, and recommended surgical excision despite the benign core biopsy pathology. CONCLUSIONS: Sonographically guided 14-gauge core needle biopsy provides a high negative predictive value in assessing breast lesions. Radiologic/pathologic correlation should be performed to avoid delay in the diagnosis of carcinoma.