Corneal neurotization.

PURPOSE OF REVIEW: Neurotrophic keratopathy is a devastating corneal condition that can lead to ocular morbidity and blindness. Current medical and surgical treatments poorly tackle the essential problem of corneal aesthesia and hence fail to provide a permanent cure. Recent advances in corneal neurotization techniques have shown promise to restore corneal nerves in neurotrophic keratopathy. This article aims at reviewing the current surgical advances, along with the current thoughts and evidence available for corneal nerve regeneration. RECENT FINDINGS: Corneal neurotization was first introduced in 2009 by Terzis et al., but recently picked up more interest since 2014. Direct and indirect neurotization are being developed, and different nerves (sural nerve, great auricular nerve) have been explored for interposition between frontal nerve branches and the cornea. New endoscopic techniques are introduced for less invasive approaches. On the corneal front, confocal microscopy and esthesiometry studies have established that the regeneration of the corneal nerves is happening 6 months after the procedure. SUMMARY: Neurotization is a budding revolutionary technique that shows promise of cure for neurotrophic corneas, but at this stage, it is still reasonably invasive and still reserved for selected patients.

Visual Outcomes and Complications of Type I Boston Keratoprosthesis in Children: A Retrospective Multicenter Study and Literature Review.

PURPOSE: To report outcomes and complications of Boston type 1 keratoprosthesis (KPro) implantation in children. DESIGN: Retrospective, multicenter case series. PARTICIPANTS: All children 16 years of age or younger who underwent KPro surgery at 3 ophthalmology centers in Canada between January 2010 and November 2014. METHODS: Records of patients having undergone KPro implantation were reviewed. Data on preoperative characteristics, surgical procedure(s) performed, and postoperative outcomes were collected and analyzed. MAIN OUTCOME MEASURES: Intraoperative and postoperative complications, device retention, and best-corrected visual acuity (BCVA). RESULTS: The KPro was implanted in 11 eyes of 11 patients 0.9 to 15.5 years of age, with 6 being primary corneal procedures. Best-corrected visual acuity recorded before surgery ranged from 20/600 to light perception (LP), and vision in 2 eyes was fix and follow. All patients had been diagnosed with glaucoma and 6 eyes had glaucoma drainage devices (GDDs) inserted before KPro implantation. At last follow-up (mean, 41.8 months; range, 6.5-85.0 months), 2 eyes retained BCVA of 20/400 or better, whereas 5 eyes lost LP. Postoperative complications included retroprosthetic membrane (9 eyes), corneal melt (5 eyes), infectious keratitis (3 eyes), endophthalmitis (3 eyes), GDD erosion (2 eyes), and retinal detachment (5 eyes). The initial KPro was retained in 4 eyes (36.4%). CONCLUSIONS: Boston type 1 keratoprosthesis implantation in children is associated with a substantially higher rate of complications, higher chance of device failure, and worse visual outcomes than observed in adults. In view of these results, the authors do not recommend the use of the KPro in the pediatric population.

Time to declare ophthalmology an independent discipline by initiating Bachelor of Ophthalmic Surgery programme.

Medical education, associated with lengthy, exhaustive pathways requisite of time, energy and efforts, restrain an individual from pursuing a career in medicine. Most students enrol in medical colleges under the influence of their family members, and only some strive to seek medicine as their own ambition. Medical students confront a number of problems in memorising huge amount of data and the various strategies are integrated in MBBS curriculum from time to time. After MBBS programme, most graduates tend to abandon studies, some migrate abroad, a few continue as general physicians and even fewer strive to get registered for postgraduate specialisation. This results in suboptimal supply of medical workforce. Inconsideration of the current ophthalmologist work ratio and growing demand for eye care services, an initiative is put forward to introduce Bachelors of Ophthalmic Surgery programme similar to Bachelor of Dental Surgery. Such initiative may facilitate effective learning, enable command in a particular area and encourage more individuals to pursue a career in ophthalmology. Using a questionnaire to undergraduate medical students, medical professors and ophthalmologists were surveyed to evaluate the efficacy of the proposed initiative. The results threw a mixed response.

NOVEL APPROACH TO SCLERAL FIXATION OF A REPER INTRAOCULAR LENS AND ARTIFICIAL IRIS COMPLEX FOLLOWING PARS PLANA LENSECTOMY AND VITRECTOMY FOR ECTOPIA LENTIS AND CATARACT IN A PATIENT WITH ANIRIDIA AND NYSTAGMUS.

PURPOSE: Prosthetic iris devices have recently been used to improve cosmesis and reduce glare in aniridia. There is currently no consensus on which prosthetic iris device or which surgical approach is preferred for managing large iris defects. METHODS: A novel surgical approach with Gore-Tex polytetrafluoroethylene sutures was used to achieve scleral fixation of an intraocular lens and artificial iris complex in a 19-year-old Caucasian female patient with aniridia, nystagmus, cataracts, and ectopia lentis. RESULTS: Six weeks postoperatively, the intraocular lens-artificial iris complex remained well centered, and the vision in the left eye improved from 20/400 to 20/70. Two years after prosthetic iris device implantation, there have been no complications. CONCLUSION: This case demonstrates a promising proof-of-concept for long-term management of complicated aniridia cases using an intraocular lens and artificial iris complex prosthetic iris devices. Gore-Tex sutures may be preferable to conventional polypropylene sutures because of their improved durability.

Randomized, prospective comparison of precut vs surgeon-dissected grafts for descemet stripping automated endothelial keratoplasty.

PURPOSE: To determine whether eye bank predissected corneal grafts provide outcomes comparable to surgeon-dissected grafts for Descemet stripping automated endothelial keratoplasty (DSAEK). DESIGN: Randomized, prospective, double-masked clinical trial. METHODS: Twenty pairs of donor corneas were harvested. One cornea from each pair was randomized to be precut at an eye bank for next-day use. The surgeon dissected the fellow cornea intraoperatively using a comparable microkeratome and protocol. The corneas were randomly assigned to 40 subjects having DSAEK at a single center. Subjects and evaluators were masked and statistical significance was assessed using the paired t test. RESULTS: Mean subject age was 71 +/- 12 years and 90% had Fuchs dystrophy. Mean endothelial cell loss was 32% at six months and 34% at one year; the two groups did not differ by a statistically significant amount at either time point (P = .10 and P = .79, respectively). Each group experienced two early dislocations (10%), and grafts were repositioned successfully with a second air bubble. At six months, 28 of 35 patients (80%) had best-corrected vision of 20/40 or better, excluding five patients (12%) with preexisting retinal problems (P = .48). Both groups experienced a mild hyperopic shift (P = .82), and neither had a statistically significant increase in mean refractive cylinder (P = .63). Histology from one subject's eye postmortem demonstrated that endothelial cells had migrated over the exposed edge of the donor stroma a year after surgery. CONCLUSIONS: Eye bank precut tissue provided similar endothelial cell loss, visual and refractive outcomes, and detachment rates compared with surgeon-dissected tissue.

Surgical techniques for the treatment of conjunctivochalasis: paste-pinch-cut conjunctivoplasty versus thermal cautery conjunctivoplasty.

OBJECTIVE: The aim of this study was to evaluate the outcomes of paste-pinch-cut conjunctivoplasty and cautery conjunctivoplasty for the treatment of symptomatic conjunctivochalasis. DESIGN: This was a prospective cohort study. PARTICIPANTS: Sixteen patients (32 eyes) with bilateral conjunctivochalasis that was symptomatic after medical therapy were enrolled in the study. METHODS: This was a single-centre, contralateral eye, prospective study. Paste-pinch-cut conjunctivoplasty was performed in the left eye, and thermal cautery conjunctivoplasty was performed in the right eye. The outcomes of each procedure were compared preoperatively and at the 1-month follow-up by using the Canadian Dry Eye Assessment (CDEA) scoring system, standard conjunctivochalasis grading, and corneal staining. Intraoperative discomfort and immediate postoperative discomfort were assessed by using a 10-point scale. RESULTS: The mean age of patients was 72.4 ± 8.67 years. Conjunctival redundancy was absent in 14 of 16 patients postoperatively. The mean CDEA score improved after both procedures (7.1 ± 2.8 preoperatively versus 4.5 ± 0.78 at the 1-month follow-up for cautery conjunctivoplasty, 7.4 ± 2.5 versus 4.9 ± 3.1 for paste-pinch-cut conjunctivoplasty). This improvement was statistically significant in the cautery conjunctivoplasty group (p = 0.012). Mean intraoperative discomfort was 2.6 ± 2.1 with the use of paste-pinch-cut conjunctivoplasty and 3.5 ± 3.2 with the use of cautery conjunctivoplasty; however, the difference was not statistically significant. No intraoperative or postoperative complications were observed with either technique. CONCLUSIONS: Paste-pinch-cut and thermal cautery conjunctivoplasty are both safe and effective surgical treatments for the repair of conjunctivochalasis, with patients reporting greater improvement in symptoms after the cautery technique.

Patient comfort and visual outcomes of mini-scleral contact lenses.

OBJECTIVE: To evaluate short-term visual outcome, patient acceptance, and tolerance of mini-scleral contact lenses (SCLs) in the management of various corneal pathologies. DESIGN: Retrospective case series. PARTICIPANTS: Thirty-two patients (40 eyes) who received mini-SCLs. METHODS: Single-centre retrospective case series, between February 2010 and January 2013, of 32 patients (40 eyes) with various corneal pathologies who were offered either Maxim 5R, Maxim 7, or Maxim 7 × 11 mini-SCLs for nonsurgical optimization of visual correction. Patients were followed up at 1 and 3 months for assessment of best-corrected visual acuity, comfort, length of daily wear, and complications. RESULTS: Thirty-two patients (40 eyes), with a mean age of 41 ± 16 years, opted to receive mini-SCLs. Eighteen patients had previously undergone surgery such as penetrating keratoplasty, deep anterior lamellar keratoplasty, and intraocular lens implantation. The median best-corrected visual acuity improved from 0.3 logMAR (range 0-1.3) before mini-SCLs, to 0.05 logMAR (range 0-1) with mini-SCLs (p < 0.0001). At 1-month follow-up, the median length of wear was 10 hours/day (range 1.5-15). At 3-month follow-up, the median length of wear was 12 hours/day (range 2-15). All eyes were comfortable at initial use of mini-SCLs and 91% were comfortable at 3-month follow-up. CONCLUSION: Mini-SCLs may be a comfortable management option for patients with keratoconus and other corneal pathologies who are unable to achieve adequate visual outcome with traditional spectacles or rigid gas-permeable contact lenses.

Long-Term Results of Phototherapeutic Keratectomy Versus Mechanical Epithelial Removal Followed by Corneal Collagen Cross-Linking for Keratoconus.

PURPOSE: To compare the long-term visual outcomes of patients with keratoconus treated with either phototherapeutic keratectomy (PTK) or mechanical epithelial removal before corneal collagen cross-linking (CXL) at 1, 3, 6, and 12 months postoperatively. METHODS: CXL was performed by 1 of 3 surgeons (K.B., W.B.J., or G.M.). Seventeen eyes underwent mechanical epithelial removal before CXL and were consecutively selected after being matched with the 17 eyes in the PTK group for the variables of procedure date, average keratometry, and pachymetry. All cones were central. Manifest refraction spherical equivalent, sphere, cylinder, corrected distance visual acuity (CDVA), and pachymetry were measured and compared preoperatively and in follow-up. RESULTS: The mean CDVA change in the PTK group at 12 months postoperatively was statistically different from the mean CDVA change in the mechanical group at 12 months postoperatively (P = 0.031). The PTK group had significantly better outcomes in visual acuity 12 months postoperatively than did the mechanical group (P > 0.05). The mean number of lines of improvement in the PTK and mechanical groups were 2.30 ± 0.96 and 0.00 ± 0.33 lines, respectively (P = 0.0036). The mean change between the preoperative and 12 months postoperative manifest refraction spherical equivalent for the PTK and mechanical groups were 0.78 ± 0.65 and 0.17 ± 0.65, respectively (P > 0.05). CONCLUSIONS: PTK CXL resulted in better visual outcomes in comparison with mechanical epithelial removal CXL 1 year after treatment.

Dual-purpose corneal tissue for anterior lamellar keratoplasty and Descemet's membrane endothelial keratoplasty.

OBJECTIVE: To assess the intraoperative issues and surgical outcomes of preparing a single-donor corneal tissue for same-day use in both deep anterior lamellar keratoplasty (DALK) and Descemet's membrane endothelial keratoplasty (DMEK). DESIGN: Consecutive retrospective case series. PARTICIPANTS: Ten eyes of 10 patients who underwent DALK (5 patients) or DMEK (5 patients) surgery using dual-purpose corneal tissue. METHODS: Five dual-purpose corneoscleral rims were used to prepare tissue for 5 DMEK and 5 DALK procedures. The submerged cornea using backgrounds away technique was first used to harvest the 5 DMEK grafts, and the remaining tissue was used for the 5 DALK grafts. Tissue preparation and operative use occurred on the same day. Tissue preparation challenges, intraoperative complications, and visual recovery were assessed. RESULTS: There were no difficulties in preparing the 5 dual-purpose tissues, and all 10 lamellar transplants were completed successfully. At the 6-month follow-up, the mean best-corrected distance visual acuity improved from 20/250 to 20/80 in the DALK patients, and from 20/300 to 20/25 in the DMEK patients. Postoperative complications after DALK included retained viscoelastic agent at the interface in 1 patient and a double anterior chamber managed with rebubbling in another. After DMEK, a peripheral partial graft detachment occurred in 1 patient and was managed successfully with rebubbling. All corneas demonstrated clarity on slit-lamp examination. CONCLUSIONS: Single-donor corneal tissue can be effectively used for both DALK and DMEK, and may represent a more efficient use of corneal tissue. Complications with the preparation of dual-purpose tissue were not encountered.

Type 1 Boston keratoprosthesis: outcomes at two Canadian centres.

OBJECTIVES: To report the outcomes of patients who underwent Boston type 1 keratoprosthesis (Kpro) surgery at the University Health Network (Toronto, Ont.) and the University of Ottawa Eye Institute (Ottawa, Ont.) between June 2008 and July 2013. DESIGN: Retrospective case series. PARTICIPANTS: Forty-four eyes of 43 patients who underwent Kpro surgery. METHODS: A retrospective review was conducted of all Kpro procedures performed by 4 attending cornea surgeons. The preoperative characteristics and postoperative course of each patient were analyzed. RESULTS: In 31 eyes (70%), the primary indication for a Kpro was failed corneal transplantation. The remaining 13 eyes (30%) had Kpro as a primary procedure. In all eyes, preoperative visual acuity (VA) was 20/150 or worse, with 39 eyes (89%) having a VA of counting fingers, hand movement, or light perception. Mean follow-up time was 21 ± 12 months (range 12-57 months). The retention rate at the last follow-up was 95%. Best-achieved median VA was 20/100 (range 20/20 to no light perception [NLP]), with 37% of patients achieving a VA of >20/40 at some point during their postoperative course. At the last follow-up, median VA was 20/400 (range 20/30 to NLP). The 2 most common complications included retroprosthetic membrane formation (23 eyes, 52%) and elevated intraocular pressure (10 eyes, 23%). There were 5 cases (11%) of stromal melt and 1 case (2%) of infective keratitis. CONCLUSIONS: This study demonstrates that Kpro improves VA in a majority of cases, and is a viable option in situations in which there is a poor prognosis for traditional penetrating keratoplasty.

Fibrin glue versus autologous blood for conjunctival autograft fixation in pterygium surgery.

OBJECTIVE: To compare the outcomes between autologous blood- and fibrin glue-fixated conjunctival autografts in pterygium excision surgery. DESIGN: Retrospective case series. PARTICIPANTS: Forty eyes of 40 patients who had a primary nasal pterygium excision. METHODS: A retrospective comparative case series of 40 eyes (40 patients) that had a primary nasal pterygium excision. All eyes had a conjunctival autograft from the superior bulbar conjunctiva to cover the scleral bed. Twenty eyes (20 patients) had fixation of the autograft using autologous blood (AB), and 20 eyes (20 patients) had fixation using fibrin glue (FG). One year of follow-up data included conjunctival graft stability (graft loss, graft retraction), pterygium recurrence, visual acuity, and postoperative complications. Descriptive and inferential statistics were performed. RESULTS: Intraoperatively, no complications occurred in either group. Graft loss occurred in 6 patients in the AB group, compared with none in the FG group. Graft retraction occurred in 3 patients in the AB group and 2 patients in the FG group. At 1 year postoperatively, pterygium recurrence occurred in 4 patients in the AB group and 1 patient in the FG group. One patient in the AB group developed a small pyogenic granuloma that resolved by 6 months with conservative management. Visual acuity remained stable in both groups. CONCLUSIONS: Conjunctival autograft fixation with autologous blood resulted in less stable conjunctival autografts and a higher recurrence rate compared with fixation with fibrin glue.

Evaluation of a new technique for preparation of endothelial grafts for descemet membrane endothelial keratoplasty.

PURPOSE: The purpose of this study was to compare the Muraine technique, a relatively new method for preparing endothelial grafts for Descemet membrane endothelial keratoplasty (DMEK), with the current standard submerged cornea using backgrounds away (SCUBA) peeling technique. METHODS: This study was a prospective ex vivo investigation. In a wet-lab setting, 20 donor corneas were prepared for DMEK using The Muraine technique and 20 donor corneas using the SCUBA technique. In each of the technique groups, 10 corneas were prepared by a corneal surgeon and 10 were prepared by a corneal fellow. Primary outcome measures were the time needed to prepare endothelial grafts and the number of graft tears. RESULTS: In the SCUBA technique, median time to prepare grafts was shorter for both the surgeon (301 ± 85 seconds) and fellow (523 ± 58 seconds) compared with the Muraine technique (surgeon, 359 ± 83 seconds; fellow, 543 ± 44 seconds). However, these findings were not statistically significant (surgeon, P = 0.33; fellow, P = 0.24; pooled, P = 0.46). There was a statistically significant difference between surgeon time and fellow time for each technique (SCUBA technique, P = 0.0005; Muraine technique, P = 0.002). In the Muraine technique, there were 5 graft tears (surgeon = 2, fellow = 3), and no graft tears in the SCUBA technique, which was statistically significant (P = 0.047). CONCLUSIONS: The present study demonstrates that the SCUBA technique may be a more effective technique to prepare endothelial donor grafts for DMEK.

Refractive outcomes in nanophthalmic eyes after phacoemulsification and implantation of a high-refractive-power foldable intraocular lens.

PURPOSE: To evaluate the refractive and postoperative outcomes of a high-power foldable intraocular lens (IOL) in nanophthalmic eyes. SETTING: Six ophthalmic surgical centers in Canada. DESIGN: Retrospective case series. METHODS: Consecutive charts of nanophthalmic patients having cataract extraction and insertion of the CT Xtreme D IOL were reviewed. Demographic and clinical data were collected, including age, sex, axial length (AL), minimum keratometry (K) value and maximum K value, corneal white-to-white (WTW), anterior chamber depth, lens thickness (LT), and complications. The following preoperative and operative data were collected: uncorrected distant visual acuity (UDVA), corrected distant visual acuity (CDVA), sphere, cylinder, and spherical equivalence (SE). The primary outcome measure was change in SE. The secondary outcome measures were changes in UDVA and CDVA. RESULTS: A total of 21 eyes from 13 patients with a mean follow-up time of 9.6 ± 8.5 months were studied. Mean preoperative data were: age (51.4 ± 15.2 years), AL (16.63 ± 0.68 mm), minimum K value (46.20 ± 2.26 D), maximum K value (47.55 ± 2.34 D), anterior chamber depth (2.60 ± 0.49 mm), WTW (11.08 ± 1.38 mm), LT (4.70 ± 0.97 mm), and IOL power implanted (+49.9 ± 3.3 diopters [D]). SE improved from +16.11 ± 3.26 D preoperatively to +2.00 ± 2.37 D postoperatively (P < .0001). UDVA improved from 1.47 ± 0.30 logMAR preoperatively to 0.74 ± 0.43 logMAR postoperatively (P = .016). CDVA did not change significantly. Five eyes (23.8%) had serious postoperative complications. Of these eyes, 2 had malignant glaucoma, 2 had vitreous hemorrhages, and 1 eye had a vitreous hemorrhage with retinal detachment resulting in visual acuity of no light perception. CONCLUSION: Implanting foldable high-power IOLs in a series of nanophthalmic eyes yielded significant improvement in UDVA and SE. Cataract surgery in these eyes carries increased risk. FINANCIAL DISCLOSURE: Iqbal Ike K. Ahmed is a consultant to Carl Zeiss Meditec AG. No other author has a financial or proprietary interest in any material or method mentioned.

Simple technique to measure toric intraocular lens alignment and stability using a smartphone.

Toric intraocular lenses (IOLs) are commonly implanted to correct corneal astigmatism at the time of cataract surgery. Their use requires preoperative calculation of the axis of implantation and postoperative measurement to determine whether the IOL has been implanted with the proper orientation. Moreover, toric IOL alignment stability over time is important for the patient and for the longitudinal evaluation of toric IOLs. We present a simple, inexpensive, and precise method to measure the toric IOL axis using a camera-enabled cellular phone (iPhone 5S) and computer software (ImageJ).

Phototherapeutic keratectomy versus mechanical epithelial removal followed by corneal collagen crosslinking for keratoconus.

OBJECTIVE: To compare the visual outcomes of patients with keratoconus treated with either phototherapeutic keratectomy (PTK) or mechanical epithelial removal prior to corneal collagen crosslinking (CXL). DESIGN: Comparative study. PARTICIPANTS: The records of 34 patients (34 eyes) who had PTK (17 eyes) or mechanical (17 eyes) epithelial removal prior to CXL for keratoconus were reviewed retrospectively. METHODS: CXL was performed by 1 of 3 surgeons (G.M., W.B.J., or K.B.). Of the eyes, 17 had undergone mechanical epithelial removal prior to CXL and were consecutively selected, after matching with the 17 eyes in the PTK group, for the variables of procedure date, average keratometry, and pachymetry. All eyes had central cones. Manifest refraction spherical equivalent, sphere, cylinder, best-corrected distance visual acuity, and pachymetry were measured and compared preoperatively and in follow-up. RESULTS: The mean change between the pre- and postoperative manifest refraction spherical equivalent for the PTK and mechanical groups was 1.68 ± 0.80 and 0.26 ± 0.90, respectively (p < 0.05). The mean change between pre- and postoperative cylinder for the PTK and mechanical groups was 0.53 ± 0.28 and 0 ± 0.18, respectively (p < 0.05). The mean number of lines of improvement in the PTK and mechanical groups were 0.33 ± 0.82 and -0.58 ± 0.45 lines, respectively (p > 0.05). CONCLUSIONS: Early results suggest that CXL with laser epithelial removal is superior to CXL with mechanical epithelial removal because it reduces refractive error in qualified patients. Although not statistically significant, there was also a trend for PTK CXL patients to have better visual outcomes.