Journal of Cornea

Peripheral Hypertrophic Subepithelial Opacities of Corneal Grafts After Deep Anterior Lamellar Keratoplasty

Feizi, Sepehr MD; Karjou, Zahra MD; Masoudi, Ali MD; Moshtaghion, Seyed-Mohamadmehdi MD; Azari, Amir A. MD

Cornea: March 2020 – Volume 39 – Issue 3 – p 271-276

Abstract

Purpose:

To investigate possible underlying etiologies of the development of peripheral graft hypertrophic subepithelial opacities (PGHSO) and to evaluate the effects of these opacities on visual outcomes after deep anterior lamellar keratoplasty (DALK).

Methods:

This prospective, interventional case series enrolled 29 eyes with keratoconus that underwent DALK and developed PGHSO (group 1). The control group consisted of 32 eyes with keratoconus that underwent DALK during the same period and had a clear graft at the final examination (group 2). Possible underlying risk factors for the development of PGHSO were investigated, and postoperative refractive and topographic outcomes were compared between the 2 study groups.

Results:

Eyes of group 1 had well-defined elevated peripheral subepithelial opacities of the corneal graft, originating from the donor–recipient junction. The central 4-mm area of the graft was clear in all eyes of this group. Compared with the controls, group 1 had flatter grafts at postoperative month 1 and a longer time interval from surgery to initial suture removal. The 2 study groups were comparable in other investigated factors, including the severity of keratoconus, surgical technique, duration of topical steroid use, and donor quality. No significant differences were observed between the case and control groups in postoperative visual acuity and graft surface regularity.

Conclusions:

Graft flattening during the early postoperative period and prolonged time interval from surgery to initial suture removal might be factors predisposing to the development of PGHSO. This complication did not affect postoperative visual outcomes when the central 4-mm area of the graft remained clear.

Corneal Collagen Cross-Linking With Photoactivated Chromophore for Infectious Keratitis After Penetrating Keratoplasty

Ozbek-Uzman, Selma MD; Yalniz-Akkaya, Zuleyha MD; Burcu, Ayse MD

Cornea: March 2020 – Volume 39 – Issue 3 – p 283-289

Abstract

Purpose:

To evaluate the efficacy and safety of corneal collagen cross-linking with photoactivated chromophore (PACK-CXL) plus medical treatment in comparison with the non-CXL group in the management of graft infections after penetrating keratoplasty.

Methods:

Forty eyes of 40 patients, 18 eyes in the PACK-CXL group and 22 eyes in the non-CXL group, with graft infections were retrospectively reviewed. Patients with microbial keratitis who were resistant to medical treatment for at least 1 week were treated with PACK-CXL in conjunction with medical treatment. The non-CXL group received only medical treatment.

Results:

The median (interquartile range) size of the infiltrate was 11 (3–۱۲.۷) versus 7.5 (3.5–۱۲.۷) mm2 (P = ۰.۳۷), the epithelization time was 3 (2.7–۵) versus 6 (3–۱۱.۲) days (P = ۰.۰۶), the complete healing time was 23.5 (17.7–۳۳.۵) versus 34 (27.7–۴۱.۲) days (P = ۰.۰۲), and the best-corrected distance visual acuity was 2.5 (0.5–۳) versus 2.0 (0.9–۳) logarithm of the minimum angle of resolution (P = ۰.۷۹) at presentation and 1 (0.3–۳) versus 3 (1–۳) logarithm of the minimum angle of resolution (P = ۰.۱۹) at the final visit for the PACK-CXL and non-CXL groups, respectively. Resolution of infiltrates was observed in 83.3% and 68.2% of cases in the PACK-CXL and non-CXL groups, respectively (P = ۰.۲۸). Graft failure was observed in 5 (27.8%) and 12 (54.5%) patients in the PACK-CXL and non-CXL groups, respectively (P = ۰.۰۸).

Conclusions:

PACK-CXL appears to be a promising adjuvant procedure in the management of resistant graft infections by reducing both the duration required for complete healing and rates of graft failure.

Five-Year Graft Survival and Clinical Outcomes of 500 Consecutive Cases After Descemet Membrane Endothelial Keratoplasty

Birbal, Rénuka S. MD; Ni Dhubhghaill, Sorcha MB, PhD; Bourgonje, Vincent J.A. PhD; Hanko, Jennifer; Ham, Lisanne PhD; Jager, Martine J. MD, PhD; Böhringer, Stefan MD, PhD; Oellerich, Silke PhD; Melles, Gerrit R.J. MD, PhD

Cornea: March 2020 – Volume 39 – Issue 3 – p 290-297

Abstract

Purpose:

To report the 5-year graft survival and clinical outcomes after Descemet membrane endothelial keratoplasty (DMEK).

Methods:

A retrospective, interventional case series was performed at a tertiary referral center. Five hundred eyes of 393 patients that underwent DMEK for Fuchs endothelial corneal dystrophy, bullous keratopathy, failed previous corneal transplants other than DMEK, or other indications were evaluated for graft survival, best-corrected visual acuity (BCVA), endothelial cell density, postoperative complications, and retransplantation rate.

Results:

Kaplan–Meier analysis demonstrated an estimated survival probability of 0.90 [95% confidence interval, 0.87–۰.۹۴] for the entire cohort at 5 years after DMEK. At this time point, 82% of the eyes achieved a BCVA of ≥۲۰/۲۵ (۰.۸), ۵۴% achieved ≥۲۰/۲۰ (۱.۰), and 16% achieved ≥۲۰/۱۷ (۱.۲). BCVA continued to improve from 6 to 36 months after DMEK surgery (P ≤ ۰.۰۰۵) and then remained stable up to 60 months postoperatively (P > 0.08). Preoperative donor endothelial cell density averaged 2530 (±۲۱۰) cells/mm2 and decreased by 37% at 6 months, 40% at 1 year, and 55% at 5 years after DMEK surgery (P < 0.001 between all follow-up time points). During the study period, allograft rejection episodes developed in 2.8% of the eyes, primary graft failure occurred in 0.2%, and secondary graft failure in 2.8% of the eyes. Re-keratoplasty was required in 8.8% of the eyes.

Conclusions:

Five-year graft survival after DMEK is high, and visual acuity outcomes remain excellent and are accompanied by a low longer-term complication rate.

Histological Corneal Alterations in Keratoconus After Crosslinking—Expansion of Findings

Müller, Philipp L. MD; Loeffler, Karin U. MD; Messmer, Elisabeth MD†; Holz, Frank G. MD; Perdikakis, Georgios MD; Kohlhaas, Markus MD; Herwig-Carl, Martina C. MD

Cornea: March 2020 – Volume 39 – Issue 3 – p 333-341

Abstract

Purpose:

To investigate histopathologic, immunohistochemical, and electron microscopic findings in 8 keratoplasty specimens with a history of corneal collagen crosslinking (CXL) for keratoconus. Five new (hitherto unreported) and 3 previously published specimens were analyzed.

Methods:

Corneal buttons of 8 keratoconus corneas (5–۱۱۴ months after CXL) were compared with 5 keratoconus specimens without CXL and 5 normal corneas for morphological alterations. Corneal buttons were evaluated by light microscopy and immunohistochemistry using antibodies against CD34, PGP 9.5, nestin, telomerase reverse transcriptase, and Ki67 as well as by transmission electron microscopy.

Results:

Keratoconus corneas after CXL showed a significant keratocyte loss (except 1 specimen with an increased keratocyte number), whereas keratoconus corneas without CXL revealed a higher keratocyte density compared with healthy controls. Keratocyte loss could be clinically correlated with corneal opacification and corneal perforation. In corneas after CXL, the remaining keratocytes appeared more polymorphic and revealed a different expression of surface markers similar to keratocytes in corneal scars. The presence of proteoglycans, nerves, and endothelial cells was unaffected by CXL.

Conclusions:

CXL may cause permanent keratocyte loss or repopulation of altered keratocytes, resulting in clinical complications such as corneal opacification or perforation. Despite its good safety profile and high effectiveness in progressive keratoconus, CXL should be performed in accordance with current guidelines strictly adhering to protocol and safety standards.

Suprachoroidal Hemorrhage During Descemet Membrane Endothelial Keratoplasty

Dockery, Philip W. MPH; Joubert, Katelyn BS; Parker, John S. MD; Parker, Jack S. MD, PhD

Cornea: March 2020 – Volume 39 – Issue 3 – p 376-378

Abstract

Purpose:

To describe two cases of suprachoroidal hemorrhage during Descemet membrane endothelial keratoplasty (DMEK).

Methods:

Two patients with pseudophakic bullous keratopathy (PBK) underwent DMEK and proceeded to develop intraoperative suprachoroidal hemorrhage. Reports of both cases are documented, including potential risk factors, intraoperative events, and postoperative outcomes and interventions.

Results:

Both cases required premature abortion of the operation following the abrupt onset of significant posterior pressure indicating potential suprachoroidal hemorrhage. Postoperative visual acuity measured light perception or worse, and both patients declined further intervention.

Conclusions:

Suprachoroidal hemorrhage is a rare but potentially devastating intraoperative complication which may occur during DMEK, particularly in eyes with relevant risk factors. An inability to deepen the anterior chamber following graft implantation may signify the condition.

Femtosecond Laser-Assisted Penetrating Keratoplasty for Treating Infective Keratitis

Hosny, Mohamed MD, FRCSEd; Marrie, Ayah MD; Anis, Mohamed MD, FRCS; El Shewy, Ahmed MD

Cornea: March 2020 – Volume 39 – Issue 3 – p 382-385

Abstract

Purpose:

To report the results of penetrating keratoplasty (PKP) assisted by femtosecond laser in the treatment of persistent infective keratitis.

Methods:

Seven eyes of 7 patients with diagnosed infective keratitis were recruited. They showed no improvement on maximal medical therapy for a week. The causative organisms were Pseudomonas aeruginosa in 3 cases and Fusarium in 4 cases. All cases underwent femtosecond laser-assisted PKP with a mushroom-shaped cut. Postoperative antimicrobial medications were continued for 8–۱۲ weeks. Sutures were removed after 6 months. Therapeutic success was defined as eradication of primary infection. Functional success was considered when visual function improves to 20/200 or better.

Results:

All 7 eyes underwent femtosecond laser-assisted PKP. There were no intraoperative complications, and all patients had uneventful recipient cornea separation. Anatomic, therapeutic, and functional success was achieved in all patients. During the 6-month follow-up period, no recurrence of infection was reported. The average preoperative corrected distance visual acuity (CDVA) was 2.07 log of the minimal angle of resolution (LogMAR) ± ۰.۲۱, whereas at 6 months postoperatively, the average CDVA was 0.17 LogMAR ± ۰.۱۳, with a P value of 0.00025.

Conclusions:

Femtosecond laser-assisted PKP was found to be an effective method for treating infective keratitis (particularly that caused by Pseudomonas aeruginosa and Fusarium) that did not respond to medical treatment. Early surgical intervention before the disease becomes advanced is recommended.