Graft Dislocation Research Articles

Autologous Retinal Transplantation for Primary and Refractory Macular Holes and Macular Hole Retinal Detachments: The Global Consortium

To report the anatomic and functional outcomes of autologous retinal transplantation (ART). Multicenter, retrospective, interventional, consecutive case series. One hundred thirty eyes of 130 patients undergoing ART for the repair of primary and refractory macular holes (MHs), as well as combined MH-rhegmatogenous retinal detachment (MH-RRD), between January 2017 and December2019. All patients underwent pars plana vitrectomy and ART, with surgeon modification of intraoperative variables. A large array of preoperative, intraoperative, and postoperative data was collected. Two masked reviewers graded OCT images. Multivariate statistical analysis and subgroup analysis were performed. Macular hole closure rate, visual acuity (VA), external limiting membrane and ellipsoid zone (EZ) band integrity, and alignment of neurosensory layers (ANL) on OCT. One hundred thirty ART surgeries were performed by 33 vitreoretinal surgeons worldwide. Patient demographics were: mean age of 63 ± 6.3 years, 58% female, 41% White, 23% Black, 19% Asian, and 17% Latino. Preoperative VA was 1.37 ± 0.12 logarithm of the minimum angle of resolution (logMAR; Snellen equivalent, approximately 20/500), which improved significantly to 1.05 ± 0.09 logMAR (Snellen equivalent, approximately 20/225; P < 0.001) after surgery (mean follow-up, 8.6 ± 0.8 months). Autologous retinal transplantation was performed for primary MH repair in 27% of patients (n= 35), for refractory MH in 58% of patients (n= 76; mean number of previous surgeries, 1.6 ± 0.2), and for MH-RRD in 15% of patients (n= 19). Mean maximum MH diameter was 1470 ± 160 μm, mean minimum diameter was 840 ± 94 μm, and mean axial length was 24.6 ± 3.2 mm. Overall, 89% of MHs closed (78.5% complete; 10% small eccentric defect), with a 95% closure rate in MH-RRD (68.4% complete; 26.3% small eccentric defect). Visual acuity improved by at least 3 lines in 43% of eyes and by at least 5 lines in 29% of eyes. Reconstitution of the EZ (P= 0.02) and ANL (P= 0.01) on OCT were associated with better final VA. Five cases of ART graft dislocation (3.8%), 5 cases of postoperative retinal detachment (3.8%), and 1 case of endophthalmitis (0.77%) occurred. In this global experience, patients undergoing ART for large primary and refractory MHs and MH-RRDs achieved good anatomic and functional outcomes, with low complication rates despite complex surgical pathologic features.

Comparison between Cryopreserved and Dehydrated Human Amniotic Membrane Graft in Treating Challenging Cases with Macular Hole and Macular Hole Retinal Detachment.

Purpose To evaluate the surgical outcomes of cryopreserved and dehydrated human amniotic membrane (hAM) graft transplantation for macular hole (MH) and macular hole retinal detachment (MHRD) repair. Materials and Methods This retrospective, interventional case series was conducted in two hospitals. Two types of hAM grafts, namely, the dehydrated form (AmnioGen, HCT Regenerative, Taiwan) and the cryopreserved form (AmnioGraft, Bio-Tissue, Miami, FL), were consecutively used in MH surgeries. Anatomical and functional outcomes between the 2 types of hAM grafts were compared. Results Seventeen patients (mean age: 62.1 ± 10.0 years, 9 (52.9%) males) were enrolled. Of them, 11 patients had persistent MH, 3 had MH without prior surgery, and 3 had MHRD. A cryopreserved hAM graft was used in 10 patients, and a dehydrated hAM graft was used in 8 patients. One patient used a cryopreserved hAM in the first MH surgery and a dehydrated hAM in the second surgery for extramacular hole with retinal detachment. After a 6-month follow-up, 13 (76.5%) patients had sealed MHs. The average visual acuity (VA) of cases with sealed MHs improved from 1.38 ± 0.62 to 1.12 ± 0.47 logMAR (p=0.03). In the other 4 cases with persistent MH, 3 had graft dislocation and 1 had a reopened MH with graft contraction. There were no significant differences in closure rate (80.00% vs. 71.43%, p=0.68) or VA improvement (0.19 ± 0.37 logMAR vs. 0.15 ± 0.41 logMAR, p=0.85) between the 2 kinds of hAM graft. Conclusion This preliminary case series showed that both cryopreserved hAM and dehydrated hAM are feasible alternative grafts for either persistent or recurrent MH. Both approaches have similar anatomical and functional outcomes.

Comparison of surgical dislocation and impacting bone graft and surgical dislocation and rotational osteotomy for the treatment of ARCO III femoral head necrosis.

Hip preserving procedures are still a challenge in late-stage osteonecrosis of femoral head (ONFH) patients. We aimed to compare the clinical outcomes of surgical dislocation and impaction bone graft and surgical dislocation and rotational osteotomy for treatment of ONFH in Association Research Circulation Osseous (ARCO) stage III patients.We retrospectively reviewed 30 ARCO stage III patients (33 hips) who had surgical dislocation and impaction bone graft or surgical dislocation and rotational osteotomy in our center from June 2012 to December 2017. Baseline characteristics, clinical evaluation using Harris score and radiologic evaluation up to 12 months after surgery were recorded and compared.Fifteen patients (17 hips) were in the surgical dislocation and impaction bone graft group and 15 patients (16 hips) were in the surgical dislocation and rotational osteotomy group. No significant differences in age, gender, etiology, ARCO stage, duration of illness, operation time, and length of hospitalization were observed between the 2 groups. Compared to preoperation Harris score, the Harris score of 6 months postoperation and 12 months postoperation significantly improved. At 12 months postoperation, the excellent and good rate was 76.5% in the impaction bone graft group and 87.5% in the rotational osteotomy group. No significant difference in Harris scores was detected in the 2 groups.Surgical dislocation and impaction bone graft and surgical dislocation and rotational osteotomy had satisfactory 1-year efficacy for ARCO III ONFH patients. Surgical dislocation and rotational osteotomy had better short-term efficacy than surgical dislocation and impaction bone graft.

Postoperative treatment compliance rate and complications with two different protocols after pterygium excision and conjunctival autografting.

To evaluate compliance rate to pterygium postoperative treatment with two different protocols. Review of clinical data of patients submitted to pterygium excision and conjunctival autografting in a single centre (and a single surgeon) in Barcelona between March 2014 and December 2017. Initial postoperative protocol (protocol 1) consisted of 4 months of topical steroids in a tapering fashion. Protocol 2 consisted of topical steroids tapered over 5 weeks. Compliance rate, complications and clinical outcomes were evaluated, and statistical comparisons were made. 120 surgeries were performed in 99 patients. Protocol 1 was applied in 63 cases and the next 57 followed protocol 2. Compliance with protocol 1 (57.6%) was lower than with protocol 2 (84.9%) (p = 0.002). Intraoperative complications (graft tear, corneal thinning, corneal perforation and bleeding) were found in 10 cases of protocol 1 and three cases of protocol 2, p = 0.08. Postoperative complications (graft dislocation, graft haematoma, ocular hypertension and recurrence) were found in 31 cases of protocol 1 (46.2%) and eight cases of protocol 2 (14%), p = 0.001. Six weeks after surgery, ocular hypertension was detected in eight cases corresponding to protocol 1 (13.6%) and two cases of protocol 2 (3.8%), p = 0.099. Recurrence rate during first year was higher in protocol 1 (26.3%) compared to protocol 2 (7.6%), p = 0.011. No cases of visual acuity worsening or infection were registered. Protocol 2 has shown to have higher compliance rate than protocol 1 and less postoperative complications, proving to be a safe and effective postoperative treatment after pterygium surgery.

Intraoperative Optical Coherence Tomography-Assisted Descemet Membrane Endothelial Keratoplasty: Toward More Efficient, Safer Surgery.

To evaluate the clinical value of intraoperative optical coherence tomography (iOCT) and prolonged overpressure in Descemet membrane endothelial keratoplasty for surgical safety, efficiency, and outcome. All Descemet membrane endothelial keratoplasties performed by the same surgeon from November 2016 through April 2018 at the University Medical Center Utrecht were included, including 6 months of follow-up. The primary outcome was the prevalence of adverse events, and the secondary outcomes included critical decision-making and surgery time. Surgeries that included prolonged (ca. 12 minutes) overpressurization of the globe were classified as group 1, and those without prolonged overpressurization of the globe were classified as group 2. In all cases, iOCT was used to determine the graft orientation, apposition, and assessment of interface fluid. A total of 38 cases were included for analysis. In groups 1 and 2, 7 (43.6%) and 4 (18.1%) adverse events, respectively, were recorded (P = 0.29). Specifically, in groups 1 and 2, 4 and 3 cases, respectively, required rebubbling because of graft dislocation (P = 0.15). In 43% of surgeries, iOCT proved to be of value for surgical decision-making. Surgery time differed significantly between groups 1 and 2 (P < 0.001) and was the result of a shortened pressurization time in group 2. iOCT provides a direct assessment of the graft orientation and apposition, allowing the surgeon to refrain from prolonged pressurization of the globe after graft insertion. Optimizing the surgical protocol using iOCT can lead to a significant reduction in surgery time without compromising surgical safety or outcome.

Posterior Segment Complications of Endothelial Keratoplasty.

Endothelial keratoplasty is the most commonly performed type of corneal transplant in the United States, currently accounting for 60% of total grafts. The anterior segment complications are well documented; however, the posterior segment complications may not be as familiar to the anterior segment surgeon. These include endophthalmitis, cystoid macular edema (CME), choroidal detachment, graft dislocation to the posterior segment, and retinal detachment. CME is the most common postoperative retinal complication with a reported incidence of up to 12.5%, which usually responds well to topical therapy. This article will review the incidence, prevention and management of posterior segment complications after endothelial keratoplasty.

Clinical Evaluation of the "Lifeline Suture" Technique for DSAEK in Cases Without Posterior Capsule Using a Novel Donor Insertion Device.

This study investigated preliminary clinical outcomes of a suture pull-through technique for Descemet stripping automated endothelial keratoplasty (DSAEK) termed the "lifeline suture" technique using a newly developed donor inserter (NS Endo-Inserter: NSI; Hoya Co, Ltd, Tokyo, Japan) in cases of bullous keratopathy without posterior capsule. Six aphakic eyes without posterior capsule from 6 patients (mean age 73.8 ± 11.9 years) with bullous keratopathy were enrolled. DSAEK alone or as a vitreocorneal surgery was performed. Donor tissue was pulled into the anterior chamber using the NSI and a 9-0 polypropylene "lifeline suture" to prevent donor tissue from slipping into the vitreous cavity, which was removed at the end of surgery. Intraoperative and postoperative complications and 6-month postoperative central donor endothelial cell densities were measured and compared with preoperative values along with 6-month best-corrected visual acuity. All donors were successfully loaded into the NSI and then pulled into the anterior chamber using the lifeline suture. No intraoperative complications, graft dislocation, or primary graft failures were noted. Six months postsurgery, mean endothelial cell density was 2027 ± 747 cells/mm (mean loss 27.2 ± 28.1%) and mean best-corrected visual acuity improved to 0.31 decimal (P = 0.018). In this preliminary case series of bullous keratopathy without posterior capsule, DSAEK outcomes using the novel NSI donor inserter with lifeline suture were comparable or better than the results expected with conventional strategies. Thus, this technique enabled apparently safe DSAEK, preventing donor migration into the vitreous cavity while maintaining a stable anterior chamber, and is suitable for complex eyes including aphakia, lacking posterior capsule, or avitreal.

Visual outcomes of Descemet Membrane Endothelial Keratoplasty at a Single Surgeon United Kingdom Centre

AbstractPurposeDescemet Membrane Endothelial Keratoplasty (DMEK) is a partial thickness corneal graft which involves replacing a recipient’s Descemet’s membrane and endothelium with healthy tissue. Main advantages include rapid visual recovery, fewer higher order aberrations and low rejection rate. However, DMEK is technically challenging and requires advanced surgical skills. The aim of the audit was to assess visual outcomes of DMEK performed at Luton and Dunstable University Hospital (L&amp;D), United Kingdom.MethodsData was collected retrospectively from April 2015 to November 2018. 57 eyes were analysed (31 male, 26 female). Patient demographic data were collected, as well as indication for surgery and pre‐operative visual acuity. Post‐operative follow‐up visits were analysed, including assessment of visual acuity, complications and graft failure and rejection.ResultsPre‐operative visual acuity (Snellen chart) ranged from worse than 6/60 to 6/6. At an average of 6 months post operatively 87% of patients achieved 6/12 vision or better. At 1 year post procedure 59% of patients achieved 6/6 vision or better. At 2 years follow‐up 63% of patients achieved 6/6 vision or better. The most common DMEK related complications were steroid induced raised IOP (n = 9), partial graft detachment or dislocation (n = 8) and need for re‐bubbling (n = 7). 5 patients were listed for Descemet Stripping Automated Endothelial Keratoplasty (DSAEK).ConclusionsMost patients undergoing DMEK procedure in L&amp;D Hospital achieve 6/12 vision or better from 6 months onwards. Outcomes at 6 months, 1 year and 2 years are in‐line with the guidelines set by the Royal College of Ophthalmologists and previously published data. These are re‐assuring findings which suggest that more advanced corneal techniques can be carried out at single surgeon sites. Future work should aim to collect long term data on outcomes.

Lower risk of graft dislocation applying organ cultured corneas compared with cold short-term cultured corneas during DSAEK surgery.

To investigate factors that may affect graft dislocation after uneventful Descemet stripping endothelial keratoplasty (DSAEK), with a special focus on different donor cornea storage conditions. All DSAEK surgeries performed during 6 years in our hospital were retrospectively investigated. Patients with previous intraocular surgeries other than cataract extraction were excluded. Donor data (age, gender, death-to-preservation time, cornea storage conditions, graft storage time, and estimated thickness of the graft) and patient information (age, gender, and indication for surgery) were noted. A total of 26 dislocations (6.6%) out of 394 DSAEK surgeries were found. The dislocation rate was considerably reduced between 2011 and 2016, due to more experienced surgeons. There was a significantly higher dislocation rate with the use of donor corneas stored in cold storage solution (12.7%) compared with organ culture solution (2.5%) (P < 0.001). During the study period, donor corneas stored in cold storage solution and organ culture solution were applied in 158 (40%) and 236 (60%) cases, respectively. There were no differences in recipient age and gender between patients who received corneas from the two storage systems, indicating a random distribution of grafts. In a multivariate analysis, only operation year (reduced rate over the years) and cold storage solution were statistically significantly associated with graft dislocation. This study suggests that the type of storage solution may have a decisive role in graft dislocation in DSAEK surgery.

Outcomes of Descemet Stripping Endothelial Keratoplasty in Eyes With Pars Plana Versus Anterior Chamber Glaucoma Drainage Devices.

To compare visual outcomes and complications of Descemet stripping endothelial keratoplasty (DSEK) in eyes with anterior chamber (AC) versus pars plana (PP) glaucoma drainage devices (GDDs). A retrospective chart review was conducted of 85 eyes that underwent DSEK and had previous or concurrent AC (37 eyes) or PP (48 eyes) GDD implantation. Outcome measures examined included visual acuity, donor dislocation rate, intraocular pressure, and secondary graft failure (SGF). The mean logarithm of the minimum angle of resolution vision improved from 1.50 (SD = 0.64) to 0.88 (SD = 0.71) in the AC group and from 1.37 (SD = 0.59) to 1.20 (SD = 0.76) in the PP group, with no significant group difference. Intraocular pressure did not differ between the groups preoperatively but was higher in the AC group compared with the PP group postoperatively [mean (SD) 14.5 (6.28) versus 11.5 (5.54) mm Hg, P = 0.03]. Graft dislocation occurred in 35.1% and 29.2% of eyes in the AC and PP groups, respectively. SGF occurred in 18.9% and 41.7% with median time 17.1 (interquartile range [IQR] 4.6-32.1) and 27.9 (IQR 15.1-34.7) months to development in the AC and PP groups, respectively. Multivariable logistic and Cox proportional hazards regression models found no statistically significant factors (tube location, age, sex, concurrent tube revision, new tube insertion) associated with either donor dislocation or SGF. There was no reduction in donor dislocation or SGF in eyes with PP compared with AC GDD, despite the decreased proximity of the shunt from the endothelial graft. Overall, GDD has a significantly adverse effect on long-term graft survival and close follow-up is warranted.

Clinical Outcomes of Descemet Stripping Endothelial Keratoplasty in Eyes With Glaucoma Drainage Devices.

In this retrospective case series of 85 eyes, 31.8% developed graft failure and graft survival was 50% at 3 years. The presence of an aqueous shunt has a significantly adverse effect on long-term graft survival. To report visual outcomes and complications of Descemet stripping endothelial keratoplasty (DSEK) in eyes with glaucoma drainage devices (GDD). A retrospective chart review was conducted of 122 procedures of 85 eyes of 83 patients who underwent DSEK and had prior or concurrent GDD implantation. Mean follow-up was 36.5±31.4 months. Patients with postoperative follow-up of <3 months were excluded from analysis. Outcome measures examined included visual acuity, donor dislocation rate, intraocular pressure (IOP), and graft survival. The mean logMAR vision improved to 1.07 postoperatively from 1.43 preoperatively, with 61% of eyes experiencing improved visual acuity. Graft dislocation occurred in 27 (31.8%) eyes and required repeat injection of air in the anterior chamber. Primary graft failure occurred in 2 (2.4%) eyes, whereas secondary graft failure occurred in 27 (31.8%) of eyes, with an average time of 24.3 months for development. Estimated survival rates at 1, 2, and 3 years were 89%, 78%, and 50%, respectively. Escalation of IOP occurred in 21 (24.7%) eyes postoperatively, where 14 eyes underwent medical therapy and 7 eyes required surgical intervention/laser for IOP control. DSEK after GDD is a viable alternative to treat endothelial dysfunction, with the majority of patients achieving visual improvement. However, aqueous shunt implantation has a significantly adverse effect on long-term graft survival and close follow-up is warranted.

Therapieoptionen bei Endotheldekompensation nach Glaukomchirurgie

During the last few years, Descemet membrane endothelial keratoplasty (DMEK) has become first line surgical treatment for patients with Fuchs endothelial dystrophy or pseudophakic bullous keratopathy. However, in eyes with previous trabeculectomy or implantation of a glaucoma drainage device, this surgical technique, where the diseased Descemet's membrane and endothelium are replaced by a lamella of donor Descemet's membrane and endothelium, may have some limitations. These include complications during surgery such as difficult unfolding of the graft in the presence of a glaucoma tube with a risk of an increased endothelial cell loss and problems after surgery like the loss of the air/gas tamponade in the anterior chamber through the opening of the trabeculectomy or the tube, with an increased risk of graft dislocation. The following review contains information on endothelial cell loss following different glaucoma operations, discusses the advantages and disadvantages of various keratoplasty techniques and gives some technical advice for improving the surgical technique.

New reconstructive surgery for radical surgical treatment of colon non-tumorous diseases

The aim — to develop new methods of reconstructive operations after radical surgery of colon non­neoplastic diseases in patients with atypical small intestine and superior mesenteric artery anatomy, as well as atypical anatomical relationship between the ileal segments and the demucosal surgical anal canal, in the presence of irritable bowel syndrome.Materials and methods. New methods of reconstructive surgery after radical surgical treatment of patients with non­neoplastic diseases of the large intestine (small bowel reservoir, ileoendoanal anastomosis method, methods of mobilization and dislocation of the small bowel graft into the pelvic cavity) have been developed. These techniques were used in 32 patients from 2008 to 2017.Results and discussion. Postoperative complications due to the implementation of reconstructive­restoration stage of surgical intervention arose in 3 (9.4 %) operated patients. Favorable functional results were obtained, in particular, the absence of diarrhea syndrome and anal incontinence syndrome in 28 (93.3 %) patients. The presence of postcollectomic syndrome I (mild) degree in 26 (86.7 %) operated patients, II (moderate) degree — in 4 (13.3 %).Conclusions. Developed methods of new reconstructive operations in the radical surgical treatment of patients with non­tumor colon diseases contributed to the uncomplicated flow of healing ileo­endoanal anastomosis, the postoperative complications frequency reduction, physiological retardation of the small intestine contents, intestinal digestion improvement, absorption, and anal hold.

A novel technique of endothelium keratoplasty: injection of corneal endothelial cells into anterior chamber

Endothelium keratoplasty(EK), due to its short operation time, fast postoperative healing and better postoperative visual prognosis, has gradually replaced penetrating keratoplasty in recent years as the preferred surgery for treating corneal endothelial decompensation.A recent study has reported the clinical results of the successful treatment of bullous keratopathy with human corneal endothelial cells cultured in vitro and anterior chamber injection, which opened a new era of EK.This method simplifies the operation procedure, avoids the complications related to the dislocation of corneal endothelial graft, and significantly improves the utilization rate of donor corneal materials.Nevertheless, long-term prognosis and outcome of patients undergoing this treatment remain to be clarified before introducing this approach into wider clinical practice. Key words: Keratoplasty; Corneal endothelial cells; Prognosis

Effect of Graft Attachment Status and Intraocular Pressure on Descemet Stripping Automated Endothelial Keratoplasty Outcomes in the Cornea Preservation Time Study

To examine the association of donor, recipient, and operative factors on graft dislocation after Descemet stripping automated endothelial keratoplasty (DSAEK) in the Cornea Preservation Time Study (CPTS) as well as the effects of graft dislocation and elevated IOP on graft success and endothelial cell density (ECD) 3 years postoperatively. Cohort study within a multi-center, double-masked, randomized clinical trial. 1090 individuals (1330 study eyes), median age 70 years, undergoing DSAEK for Fuchs endothelial corneal dystrophy (94% of eyes) or pseudophakic or aphakic corneal edema (6% of eyes). Recipient eyes receiving donor corneal tissue randomized by preservation time (PT) of 0-7 days (N = 675) or 8-14 days (N = 655) were monitored for early or late graft failure through 3 years. Donor, recipient, operative, and postoperative parameters were recorded including graft dislocation (GD), partial detachment, and pre- and post-operative IOP. Pre- and postoperative central donor ECD were determined by a central image analysis reading center. Proportional hazards, mixed effects, and logistic regression models estimated risk ratios and (99% confidence intervals). Three independent predictive factors for GD were identified: a history of donor diabetes (odds ratio [OR]: 2.29 [1.30, 4.02]), increased pre-lamellar dissection central corneal thickness (OR: 1.13 [1.01, 1.27] per 25µ increase), and operative complications (OR: 2.97 [1.24, 7.11]). Among 104 (8%) eyes with GD, 30 (28.9%) developed primary donor or early failure and 5 (4.8%) developed late failure vs. 15 (1.2%; P < .001) and 29 (2.4%; P = .04), respectively, of 1226 eyes without GD. 24 (2%) of 1330 study eyes had early acutely elevated postoperative IOP that was associated with a higher risk of graft failure through 3 years (hazard ratio: 3.42 [1.01, 11.53]), but not with a lower mean 3-year ECD (mean difference 61 (-479, 601) cells/mm2, P = .77). History of elevated postoperative IOP beyond 1 month was not significantly associated with 3-year graft success or ECD. Donor diabetes, increased donor corneal thickness, and intraoperative complications were associated with an increased risk of GD. Early acutely elevated postoperative IOP and GD significantly increased the risk for graft failure following DSAEK.

Postoperative Endothelial Cell Density Is Associated with Late Endothelial Graft Failure after Descemet Stripping Automated Endothelial Keratoplasty

To determine whether preoperative endothelial cell density (ECD) and postoperative ECD after Descemet stripping automated endothelial keratoplasty (DSAEK) are associated with late endothelial graft failure (LEGF) in the Cornea Preservation Time Study (CPTS). Cohort study within a multicenter, randomized clinical trial. A total of 1007 individuals (1223 study eyes), mean age 70 years, undergoing DSAEK for Fuchs' dystrophy (94% of eyes) or pseudophakic or aphakic corneal edema (PACE) (6% of eyes) and followed for up to 5 years. Central ECD was determined by a central image analysis reading center. Preoperative ECD was determined for 1209 eyes that did not fail and 14 eyes that experienced LEGF. The ECD at 6 and 12 months after DSAEK, the change in ECD from preoperative to 6 and 12 months, surgeon-reported operative complications, and postoperative graft dislocation were investigated for an association with LEGFs unrelated to other postoperative events. Univariable and multivariable Cox proportional hazards regression models were used to assess associations. Late endothelial graft failure and its associations with pre- and postoperative ECD and operative complications. The cumulative probability of LEGF was 1.3% (95% confidence interval [CI], 0.8%-2.4%). Median (interquartile range [IQR]) preoperative ECDs were similar for eyes with LEGF (2523; 2367-3161) cells/mm2) and eyes without failure (2727; 2508-2973) cells/mm2) (P= 0.34). The ECD at 6 months was associated with LEGF (P< 0.001) in time-to-event analyses, whereas preoperative ECD was not (P= 0.55). The cumulative incidence (95% CI) of LEGF was 6.5% (3.0%, 14.0%) for 97 grafts with a 6-month ECD less than 1200 cells/mm2, 0.3% (0.0%, 2.4%) for 310 grafts with a 6-month ECD between 1200 and 2000 cells/mm2, and 0.6% (0.1%, 2.7%) for 589 grafts with a 6-month ECD greater than 2000 cells/mm2. In multivariable analyses, ECD at 6 months and operative complications were both associated with LEGF (P= 0.002 and P= 0.01, respectively), whereas graft dislocation was not (P= 0.61). In eyes undergoing DSAEK, preoperative ECD is unrelated to LEGF, whereas lower ECD at 6 months is associated with LEGF. Early endothelial cell loss after DSAEK and intraoperative complications should be minimized to improve graft survival.

Points to consider before the insertion of maxillary implants: the otolaryngologist's perspective.

Maxillary implants are inserted in the upward direction, meaning that they oppose gravity, and achieving stable support is difficult if the alveolar bone facing the maxillary sinus is thin. Correspondingly, several sinus-lifting procedures conducted with or without bone graft materials have been used to place implants in the posterior area of the maxilla. Even with these procedures available, it has been reported that in about 5% of cases, complications occurred after implantation, including acute and chronic sinusitis, penetration of the sinus by the implant, implant dislocation, oroantral fistula formation, infection, bone graft dislocation, foreign-body reaction, Schneiderian membrane perforation, and ostium plugging by a dislodged bone graft. This review summarizes common maxillary sinus pathologies related to implants and suggests an appropriate management plan for patients requiring dental implantation.

Phakic intraocular lens as a temporary barrier in aphakic Descemet's membrane endothelial keratoplasty.

Descemet's membrane endothelial keratoplasty has a lower risk of endothelial rejection than Descemet's stripping automated endothelial keratoplasty. In aphakic eyes requiring endothelial transplantation, approaches aimed at reducing the risk of posterior graft dislocation in Descemet's stripping automated endothelial keratoplasty are not transferable to Descemet's membrane endothelial keratoplasty. Here we describe the use of an implantable collamer lens placed over the iris to provide a temporary intraoperative platform, to facilitate graft unfolding and to avoid posterior graft dislocation in an aphakic, vitrectomised eye with a fixed, dilated pupil in a young patient with chronic uveitis and previous failed Descemet's stripping automated endothelial keratoplasty.

COMBINED AUTOLOGOUS TRANSPLANTATION OF NEUROSENSORY RETINA, RETINAL PIGMENT EPITHELIUM, AND CHOROID FREE GRAFTS.

To evaluate the feasibility and initial functional and anatomical outcomes of transplanting a full-thickness free graft of choroid and retinal pigment epithelium (RPE), along with neurosensory retina in advanced fibrosis and atrophy associated with end-stage exudative age-related macular degeneration with and without a concurrent refractory macular hole. During vitrectomy, an RPE-choroidal and neurosensory retinal free graft was harvested in nine eyes of nine patients. The RPE-choroidal and neurosensory retinal free graft was either placed subretinally (n = 5), intraretinally to cover the foveal area inside an iatrogenically induced macular hole over the RPE-choroidal graft (n = 3) or preretinally (n = 1) without a retinotomy wherein both free grafts were placed over the concurrent macular hole. Silicone oil endotamponade was used in all cases. Mean follow-up was 7 ± 5.5 months (range 3-19). The mean preoperative visual acuity was ∼count fingers (logarithm of the minimum angle of resolution = 2.11, range 2-3), which improved to ∼20/800 (logarithm of the minimum angle of resolution 1.62 ± 0.48, range 0.7-2, P = 0.04). Vision was stable in 5 eyes (55.6%) and improved in 4 eyes (44.4%). Reading ability improved in 5 eyes (55.6%). Postoperative complications were graft atrophy (n = 1), epiretinal membrane (n = 1), and dislocation of neurosensory retina-choroid-RPE free graft (n = 1). Combined autologous RPE-choroid and neurosensory retinal free graft is a potential surgical alternative in eyes with end-stage exudative age-related macular degeneration, including concurrent refractory macular hole.

Descemet's membrane endothelial keratoplasty (DMEK) versus Descemet's stripping automated endothelial keratoplasty (DSAEK) for corneal endothelial failure.

Corneal endothelial transplantation has become the gold standard for the treatment of corneal endothelial dysfunctions, replacing full thickness transplantation, known as penetrating keratoplasty. Corneal endothelial transplantation has been described using two different techniques: Descemet's membrane endothelial keratoplasty (DMEK) and Descemet's stripping automated endothelial keratoplasty (DSAEK). Both are still performed worldwide. To compare the effectiveness and safety of Descemet's membrane endothelial keratoplasty (DMEK) versus Descemet's stripping automated endothelial keratoplasty (DSAEK) for the treatment of corneal endothelial failure in people with Fuch's endothelial dystropy (FED) and pseudophakic bullous keratopathy (PBK). We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2017, Issue 7); MEDLINE Ovid; Embase Ovid; LILACS BIREME; the ISRCTN registry; ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). The date of the search was 11 August 2017. We included randomised controlled trials (RCTs) and non-randomised paired, contralateral-eye studies in any setting where DMEK was compared with DSAEK to treat people with corneal endothelial failure. Two review authors independently screened the search results, assessed trial quality and extracted data using the standard methodological procedures expected by Cochrane. Our primary outcome was best corrected visual acuity (BCVA) measured in logarithm of the Minimum Angle of Resolution (logMAR). Secondary outcomes were endothelial cell count, graft rejection, primary graft failure and graft dislocation. We graded the risk of bias of non-randomised studies (NRSs) using ROBINS-I. We did not identify any RCTs but found four non-randomised studies (NRSs) including 72 participants (144 eyes), who had received DSAEK in the first eye followed by DMEK in the fellow eye. All the studies included adult participants where there was evidence of FED and endothelial failure requiring a corneal transplant for the treatment of visual impairment. We did not find any studies that included PBK. The trials were published between 2011 and 2015, and we assessed them as high risk of bias due to potential unknown confounding factors since DSAEK preceded DMEK in all participants. Two studies reported results at 12 months, one at 6 months, and one between 6 and 24 months. At one year, using DMEK in cases of endothelial failure may result in better BCVA compared with DSAEK (mean difference (MD) -0.14, 95% confidence interval (CI) -0.18 to -0.10 logMAR, 4 studies, 140 eyes, low-certainty evidence). None of the participants had severe visual loss (BCVA of 1.0 logMAR or more; very low-certainty evidence). Regarding endothelial cell count data (4 studies, 134 eyes) it is hard to draw any conclusions since two studies suggested no difference and the other two reported that DMEK provides a higher cell density at one year (very low-certainty evidence). No primary graft failure and only one graft rejection were recorded over four studies (144 eyes) (very low-certainty evidence). The most common complications reported were graft dislocations, which were recorded in one or two out of 100 participants with DSAEK but were more common using DMEK, although this difference could not be precisely estimated (risk ratio (RR) 5.40, 95% CI 1.51 to 19.3; 4 studies, 144 eyes, very low-certainty evidence). This review included studies conducted on people with corneal endothelium failure due to FED for whom both DMEK and DSAEK can be considered, and found low-certainty evidence that DMEK provides some advantage in terms of final BCVA, at the cost of more graft dislocations needing 're-bubbling' (very low-certainty of evidence).