Clinical and Morphologic Outcomes of Minimally Invasive Direct Corneal Neurotization.

PURPOSE: To describe clinical outcomes of a minimally invasive technique for direct corneal neurotization to treat neurotrophic keratopathy. METHODS: All cases of corneal neurotization for neurotrophic keratopathy performed by a single surgeon using minimally invasive direct corneal neurotization were reviewed. The supraorbital donor nerve was directly transferred to the cornea through an upper eyelid crease incision using either a combination of endoscopic and direct visualization or direct visualization alone. Detailed ocular and adnexal examinations as well as Cochet-Bonnet esthesiometry of the affected cornea were performed. Corneal histopathology and in vivo confocal microscopy after minimally invasive direct corneal neurotization were reviewed in one patient who underwent simultaneous penetrating keratoplasty. RESULTS: Five consecutive cases in 4 patients were included, with a mean follow up of 15.8 months (range: 11-23 months). Average denervation time was 17.8 months (range: 6-24 months). Baseline corneal conditions were Mackie stage 1 (20%), Mackie stage 2 (40%), and Mackie stage 3 (40%). All patients demonstrated improvements in corneal sensibility and appearance postoperatively. All patients demonstrated stable or improved visual acuity. No patients developed persistent epithelial defects postoperatively, and all achieved return of tactile skin sensation in the donor nerve sensory distribution. In vivo confocal microscopy after minimally invasive direct corneal neurotization and simultaneous penetrating keratoplasty demonstrated regeneration of corneal nerves. Complications included an asymptomatic small bony excrescence lateral to the supraorbital notch in one patient and cataract progression in the patient who underwent penetrating keratoplasty. CONCLUSIONS: Minimally invasive direct corneal neurotization is a safe and effective treatment of neurotrophic keratopathy.

Analysis of resident-performed manual small incision cataract surgery (MSICS): an efficacious approach to mature cataracts.

To examine and improve outcomes of resident-performed manual small incision cataract surgery (MSICS) cases via analysis of visual recovery, intraoperative adverse events, and early postoperative course. Particular focus was directed toward mature cataracts extracted by MSICS. A retrospective review was performed to identify MSICS cases performed by resident surgeons unfamiliar with the technique (initial ten cases) in an academic setting. Preoperative history, intraoperative adverse events, and postoperative course were reviewed. Of 30 cases identified, mean preoperative acuity was 1.8 ± 0.9 logMAR units (Snellen equivalent = 20/1262) improving to 0.20 ± 0.35 logMAR units (20/31) at final follow-up (p < 0.0001). Mean follow-up was 22.1 ± 19.0 days. The most frequent intraoperative adverse events were wound leak requiring intraoperative suturing (33 %), vitreous loss (6.7 %), and capsulorhexis radialization (6.7 %). Transient cornea edema was the most frequent (56.7 %) early postoperative minor complication. Two major complications occurred that required wound revision in one eye and iridoplasty in one eye. Of the 30 eyes undergoing surgery, 19 were noted to have mature cataracts. In this subset, mean acuity was 2.25 ± 0.64 logMAR units (20/3557) improving to 0.28 ± 0.42 logMAR (20/38) at final follow-up (p < 0.0001). Complications were similar in nature and frequency to the entire population in this subgroup. Supervised resident MSICS cataract surgery can result in excellent anatomic and visual outcomes. Appropriate wound construction is a frequently encountered difficulty, so particular attention should be directed to this step by both trainers and trainees.

Influence of Lens Status on Outcomes of Descemet Membrane Endothelial Keratoplasty.

PURPOSE: To evaluate whether lens status influences clinical outcomes of Descemet membrane endothelial keratoplasty (DMEK) in patients who underwent DMEK in phakia, pseudophakia, or combined with cataract surgery (triple). METHODS: A retrospective review of 139 eyes (107 patients) with symptomatic Fuchs' dystrophy or secondary corneal edema was performed. Patients were divided into 3 groups: 1) DMEK + cataract surgery, 2) DMEK in pseudophakia, and 3) DMEK in phakia. RESULTS: Of 139 DMEK surgeries, 61 were DMEK triple (43.9%), 55 pseudophakic DMEK (39.6%), and 23 phakic DMEK (16.5%) procedures. Rebubble occurred in 31 of 134 eyes (23.1%), of which 17 were in eyes after DMEK triple (28.3%), 10 after pseudophakic DMEK (19.6%), and 4 after phakic DMEK (17.4%). There was no statistically significant difference in rebubble rates depending on lens status (P = 0.548). There was no statistically significant difference in best corrected visual acuity (BCVA) between eyes that underwent rebubble versus not (P = 0.854). BCVA in patients post-DMEK was 20/25 or better in 81% of cases, and mean BCVA was 20/23. Donor age (P = 0.889), graft cell count (P = 0.525), and graft preparation technique (P = 0.769) were not predictive of rebubbling. CONCLUSIONS: Our study demonstrates no difference in DMEK outcome with regard to rebubble rate whether the procedure is performed in combination with cataract surgery, in pseudophakia, or in phakia. Furthermore, donor age, initial graft cell count, and graft preparation technique did not impact rebubble rate. BCVA was also not affected by the need for rebubbling.

Cytokeratin 12 in human ocular surface epithelia is the antigen reactive with a commercial anti-Galpha q antibody.

PURPOSE: In our initial attempt to identify differentiation markers for ocular surface epithelia, we observed a unique staining pattern by a commercial anti-Galphaq antibody. We further isolate and characterize the protein reactive with this anti-Galphaq antibody in human ocular surface epithelia. METHODS: Human donor corneoscleral buttons were sectioned and stained with a battery of commercial antibodies against Galpha proteins. Western blot analysis of cell lysates of corneal epithelial cells and HEK 293 cells transfected with Galphaq cDNA was used to determine the identity of the protein reactive with the anti-Galphaq antibody (E-17). Comparisons were made with another anti-Galphaq antibody (G4415) and an anti-cytokeratin 12C (J7) antibody. The isolated proteins reactive with E17 and J7 were then analyzed with two dimensional isoelectric focusing. Polypeptide sequences were identified using matrix assisted laser desorption/ionization time of flight mass spectrometry (MALDI-TOF MS) after in-gel protein digestion. RESULTS: The E-17 anti-Galphaq antibody preferentially stained the entire corneal epithelia and the suprabasal layers of the limbus with complete absence of staining in the basal limbus and conjunctiva. Western blot analysis of corneal epithelial cells showed that E-17 antibody identified a protein with a molecular weight of 55 kDa. However, the antibody did not react with the purported antigen, Galphaq protein (42 kDa) produced by Galphaq cDNA. Another anti-Galphaq antibody (G4415) did not react with the 55 kDa protein but did react with the 42 kDa Galphaq protein. Further comparison of the E-17 antibody with the J7 antibody revealed that both recognized the 55 kDa band in one and two dimensional analysis. MALDI-TOF MS analysis confirmed that the 55 kDa protein of interest was actually cytokeratin 12 (CK12), rather than Galphaq protein. CONCLUSIONS: The commercial E-17 anti-Galphaq antibody did not react with Galphaq protein, its purported antigen. Instead, it recognized a 55 kDa protein, which was characterized to be cytokeratin 12 by isoelectric focusing and peptide fingerprinting with mass spectrometry. Based on its reactivity with CK12, this commercial E-17 can be used as a differentiation marker to study ocular surface epithelia.

Identification of the promoter region of the human betaIGH3 gene.

PURPOSE: To isolate and characterize the promoter of the human betaIGH3 gene. METHODS: Primer extension and CapSite Hunting methods were used to determine the transcription start sites (TSS) of the human betaIGH3 gene. Putative transcription factor-binding sites and potential promoter regions were identified by online tools. Two clones containing 3 Kb and 1 Kb of the 5'-flanking region of the betaIGH3 gene were isolated and their respective promoter activities were characterized. Various fusion constructs of betaIGH3 promoter-luciferase reporter were made to transfect A549 cells. The responses of these fragments to TGF-beta1 were also measured after being treated with TGF-beta1 at different concentrations. Several human and nonhuman cell lines were also transfected with the 1 Kb betaIGH3 promoter-reporter construct to compare the activity of the betaIGH3 promoter in these cells. RESULTS: The transcription start site of human betaIGH3 mRNA was determined to be 65 bp upstream of the ATG start codon. Both the 3 Kb (-3011 to -1) and 1 Kb (-1000 to -1) fragments displayed strong and comparable promoter activity in transfected cells. Truncation analyses in A549 cells identified the nucleotide region from -336 to -1 as having high promoter activity (minimal promoter). The results also indicated that the nucleotide fragment from -1000 to -646 contained negative regulatory elements. Twenty ng/ml TGF-beta1 upregulated the activity of the 1 Kb construct, but did not upregulate the activity of the -336 to -1 construct, suggesting that TGF-beta1 responsive elements existed in the region from -1000 to -336. The 1 Kb construct universally demonstrated promoter activity in all cell lines tested. CONCLUSIONS: We identified the betaIGH3 gene promoter with a distinct regulatory pattern in the 1 Kb region upstream of the ATG start codon. Further elucidation of the functions of this promoter region may facilitate understanding of betaIGH3 and its related corneal dystrophies.

First report of keratitis in familial cold autoinflammatory syndrome.

OBJECTIVE: To report corneal manifestations of familial cold autoinflammatory syndrome (FCAS) for the first time. DESIGN: small case series PARTICIPANTS: Medical records of three members of a single family were reviewed after obtaining institutional review board (IRB) approval and informed consent. METHODS: All three members presented with a long history of maculopapular rash after cold exposure starting in childhood associated with nausea, low-grade fever, fatigue and arthralgia that lasted less than 24 hours. Their ocular manifestations consisted of ocular pain, photophobia and keratitis with subsequent stromal haziness. RESULTS: Patients underwent systemic therapy with canalinumab (Ilaris). They responded very well to repeated injections of Ilaris without side effects. CONCLUSIONS: FCAS causes lifelong debilitating effects that restrict patients' daily activities. Ilaris is an FDA-approved treatment for this condition and that typically results in dramatic improvement in clinical and laboratory measures of inflammation, and is well tolerated. Our report is the first small case series of FCAS with keratitis that responded to Ilaris beautifully.

Documentation of conformance to preferred practice patterns in caring for patients with dry eye.

OBJECTIVE: To evaluate documentation of physician evaluations of patients with dry eye for the presence of key elements as defined in the American Academy of Ophthalmology Summary Benchmarks for Preferred Practice Patterns. METHODS: One hundred thirty-one medical records of patients seen at the Duke Eye Center from January 1998 to July 2008 were reviewed relative to both the dry eye preferred practice patterns benchmarks for 1998 (all patients) and 2003 (for those seen between 2004 and 2008). Overall total score and subsection scores were calculated for all patients, as well as by specialty provider types and by type of medical record (electronic vs paper). RESULTS: Of all records reviewed, 84.8% were for women and the mean (SD) age of all patients was 60.3 (20.8) years. On average, 66.4% of the initial history key elements, 77.3% of the initial physical examination key elements, 40.0% of care management key elements, and 67.9% of patient education key elements were documented. The physical examination scores were highest in the "other" subspecialty ophthalmologist group compared with the comprehensive ophthalmologist group (P = .03) and cornea specialists (P = .02). The physical examination scores were 87% in the electronic medical record and 75% in the standard paper medical record (P < .001) groups. CONCLUSIONS: In an academic practice, the process of care delivery for dry eye does conform to the American Academy of Ophthalmology Preferred Practice Patterns in some areas; however, there is room for improvement especially in the areas of patient education and care management. Additional data are needed from other practice settings to further evaluate the quality of dry eye care.

Interleukin-6 as a photoreceptor neuroprotectant in an experimental model of retinal detachment.

PURPOSE: To test the hypothesis that interleukin (IL)-6 prevents photoreceptor cell death during periods of retinal separation from the retinal pigment epithelium (RPE). METHODS: Retinal-RPE separation was created in wild-type C57BL mice, IL-6(-/-) mice, and Brown Norway rats by subretinal injection of 1% hyaluronic acid. In some animals, anti-IL-6 neutralizing antibody (NAB) or exogenous IL-6 was administered into the subretinal space at the time of separation or at specified times afterward. Terminal deoxynucleotidyl transferase dUTP nick-end labeling (TUNEL) was performed 3 days after separation to detect apoptotic photoreceptors. Photoreceptor cell counts were performed after 1 and 2 months. RESULTS: Loss of IL-6 function through genetic ablation (IL-6(-/-) mice) or injection of anti-IL-6 NAB resulted in significantly increased levels of TUNEL-positive staining 3 days after retinal-RPE separation. One month after separation, outer nuclear layer (ONL) cell counts were significantly lower in IL-6(-/-) mice or in animals injected with anti-IL-6 NAB than in controls. Gain of IL-6 function through the addition of exogenous IL-6 resulted in significantly increased ONL counts at 1 month but not at 2 months. Reinjection of IL-6 at 1 month led to continued preservation of ONL counts compared with controls. A window of opportunity for treatment was detected because delaying injection of exogenous IL-6 to 2 weeks after retinal-RPE separation still resulted in significantly greater ONL cell counts compared with controls. CONCLUSIONS: IL-6 may serve as a photoreceptor neuroprotectant in the setting of retinal-RPE separation.

Malignant fibrous histiocytoma of the lateral conjunctiva and anterior orbit.

A 25-year-old woman presented for evaluation of a rapidly enlarging mass of the left bulbar conjunctiva. Debulking biopsy was performed, which led to the diagnosis of myxoid malignant fibrous histiocytoma. The patient underwent left orbital exenteration with clear margins. Histopathology showed involvement of the conjunctiva substantia propria, superior conjunctival fornix, and episclera, as well as extension from the lateral rectus muscle sheath. Immunohistochemical staining was strongly positive for CD68, alpha1-antitrypsin, CD34, and vimentin.