Postoperative Wound Leak Research Articles

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.

A novel approach of subconjunctival Mitomycin C injection at the end of trabeculectomy for secondary glaucoma: A pilot study

Purpose: To describe for the first time, a new approach of subconjunctival Mitomycin-C (MMC) injection at the end trabeculectomy for secondary glaucoma. Materials and Methods: This pilot study consisted of 4 eyes of 4 patients of uncontrolled secondary glaucoma. After preoperative glaucoma workup, all patients underwent standard trabeculectomy with subconjunctival MMC injection, 0.1ml (0.02mg) in superonasal quadrant at the end of surgery. Postoperative follow-up included assessment of visual acuity, intraocular pressure (IOP), bleb, anterior chamber depth and for any complications. The success criterion was IOP of ?21 mmHg. Results: The mean pre and postoperative IOP were 43 mmHg± 16.2 and 12.00mmHg ± 1.6 respectively with a success rate of 100% during a mean follow up of 15.5 months. Blebs were mildly elevated, diffuse and less avascular. No intraoperative complications were seen. Postoperative wound leak, flat anterior chamber, hypotony, choroidal detachment or endophthalmitis were not encountered. Conclusion: This novel approach of subconjunctival MMC injection at the end of trabeculectomy was found to be safe and highly effective in secondary glaucoma without any MMC related complications. Keywords: Mitomycin C, Subconjunctival injection, Secondary glaucoma, Trabeculectomy.

Intraoperative ciliary body inflammation as a masquerade for postoperative wound leak following manual small-incision cataract surgery

Intraoperative ciliary body inflammation as a masquerade for postoperative wound leak following manual small-incision cataract surgery

Incidence, Risk Factors and Outcomes of Endophthalmitis Following Intravitreal Dexamethasone Implant in a Tertiary Eye Unit

Aim: Review of current literature regarding infection rates following intravitreal dexamethasone implant shows very little real-world data to date. Comparisons with infection rates following anti-VEGF or triamcinolone injections may not be clinically useful due to differing procedures and localised drug effects. We report the first direct clinical data on endophthalmitis rates following intravitreal dexamethasone implants in a tertiary eye unit in the UK. Methods: Retrospective study of electronic patient records of all endophthalmitis cases between March 2010 and March 2018, with identification of dexamethasone-related cases. Review of treatment given, visual outcomes and possible risk factors. Results: From 947 documented injections, 3 endophthalmitis cases were identified, giving a post-operative endophthalmitis rate of 0.32%. Conclusion: Our data show a higher rate than previously published. Discussion of the cases reveals one case in a previously vitrectomised eye with post-operative wound leak. This may represent a risk factor for infection, but small numbers currently prevent useful statistical analysis. We discuss modifications to the protocol in our unit based on our experiences and available evidence.

Descemet Membrane Endothelial Transfer: Ultimate Outcome.

To evaluate the clinical outcome of 16 eyes undergoing Descemet membrane endothelial transfer (DMET). In this retrospective cohort study, a consecutive series of 16 eyes from 16 patients was evaluated after subtotal detachment of the Descemet graft after a Descemet membrane endothelial keratoplasty procedure (n = 8) or intended DMET (n = 8) for either Fuchs endothelial dystrophy (n = 10) or bullous keratopathy (BK; n = 6). All 8 Descemet membrane endothelial keratoplasty procedures were complicated by subtotal detachment of the donor graft. The remaining 8 eyes that underwent a DMET procedure were uneventful and no postoperative complications occurred, except 1 eye with BK that experienced a postoperative wound leak. Throughout all postoperative time points, the partially attached status of all Descemet grafts was maintained. Although all eyes operated on for Fuchs endothelial dystrophy showed initial central corneal clearance, no eye operated for BK demonstrated any degree of corneal deturgescence. Ultimately, all 16 corneas decompensated and 15 of the 16 patients elected retransplantation, while 1 patient declined further surgery for health reasons. Retransplantation was performed on average 10.3 (±7.4) months (range, 3-31 mo) postoperatively. Ultimately, regardless of the etiology of endothelial dysfunction, DMET fails to provide satisfactory results in the long term; durable corneal clearance may therefore require the presence of a nearly completely attached Descemet graft.

Enhanced Trabeculectomy: The Moorfields Safer Surgery System.

Trabeculectomy with antifibrotic treatment is still the most popular incisional procedure for glaucoma filtration surgery (GFS) worldwide. The advent of antifibrotic agents reduced failure due to scarring but resulted in increased complications. Advances in trabeculectomy surgery have been driven by the need to minimise the risk of: (1) complications and (2) surgical failure. This chapter covers preoperative, intraoperative, and postoperative strategies, which improve the outcome of GFS. Strategies to reduce the risk of complications centre on the prevention of postoperative hypotony by minimising the risk of overdrainage, postoperative wound leaks, and poor bleb morphology. Surgical techniques to reduce the risk of postoperative fibrosis by the use of antifibrotic agents (including mitomycin C) are discussed in detail. These techniques are based on a combination of considerable clinical experience, observation, and laboratory research. The need to address pre-, intra-, and postoperative issues in each individual patient is emphasised. These changes are embodied in the system we call the "Moorfields Safer Surgery System." The use of these strategies has considerably reduced the incidence of major complications, including hypotony, cystic blebs, and endophthalmitis in practices around the world. Most of these techniques are simple, require minimal equipment, and can be easily mastered. They are associated with an improvement in overall outcome and it is hoped that this chapter will help the reader benefit from these advances.

Wound-related complications and clinical outcomes following open globe injury repair.

Careful surgical management of traumatic wounds is important in open globe injury repair. This study examines the clinical outcomes following repair of open globe injuries with particular focus on wound-related issues. Retrospective, cohort study of consecutive open globe injuries presenting to a tertiary referral eye hospital from 1 January 2009 to 31 December 2011. A total of 267 eyes of 263 patients, mainly male (82.5%) with a mean age of 44.8 (range: 4-97) years. Average follow up was 6.9 months. All cases classified according to Ocular Trauma Classification Group. Visual outcomes, risk factors for and rates of postoperative complications and endophthalmitis. There were 83 globe ruptures, 182 penetrating and 2 perforating eye injuries, of which 43 cases had intraocular foreign body. Factors contributing to final visual acuity (VA) <6/60 were poor presenting VA (odds ratio [OR] = 16.0, 95% confidence interval [CI]: 4.81-53.1), globe rupture (OR = 4.64, [1.99-10.8]), retinal detachment (OR = 3.40, [1.19-9.74]) and age ≥50 (OR = 2.45, [1.05-5.74]). Wound leak occurred in 44 eyes (16%). Of these, 18 (41%) proceeded to re-suturing. Factors contributing to wound leak were stellate-shaped wound (OR = 3.28, [1.39-7.73]) and delayed presentation (OR = 2.80, [1.02-7.71]). Ten eyes (3.7%) developed endophthalmitis. Factors associated with endophthalmitis were delayed presentation (OR = 8.91, [1.71-46.6]), microbial keratitis (OR = 12.5, [1.85-85.0]) and lens capsule breach (OR = 12.4, [1.85-83.1]). Wound leak is an important postoperative complication of open globe injury repair. Delayed presentation is an important risk factor for postoperative wound leak and endophthalmitis. Prompt and meticulous wound management of open globe injury may reduce these complications.

Use of a calibrated force gauge in clear corneal cataract surgery to quantify point-pressure manipulation

To develop and evaluate a calibrated force gauge designed to simulate the effect of patient-induced manipulation of the eye with resultant elevation of intraocular pressure (IOP) and use the device to determine the stability of cataract incisions. Three private practice study sites. Clinical trials. A calibrated force gauge was developed to apply controlled and quantifiable amounts of force to the eye. In study 1, the calibrated force gauge was used to evaluate the change in IOP during application of 1 oz of external force in a group of healthy volunteers. In studies 2 and 3, the calibrated force gauge was used to assess wound leakage of clear corneal incisions that were subjected to stromal hydration or sutures, respectively. In study 1, with the application of 1.00 oz of external force, the mean IOP rose from a baseline of 17.49 mm Hg to 43.44 mm Hg. In study 2 (stromal hydration) using up to 1.00 oz of force, the leak rate was 67% for the main incision. The overall leak rate for study 3 (sutures) using up to 1.00 oz of force was 23.8%. No adverse events or serious adverse events occurred during these studies. Study 1 confirmed that 1.00 oz of force is a realistic approximation of the amount of force a patient's eye may experience during rubbing. After clear corneal cataract surgery, the application of 1.00 oz of force to the ocular surface for approximately 2 to 3 seconds may simulate the propensity for postoperative wound leak resulting from patient manipulation.

Outcomes of Same-Sizing versus Oversizing Donor Trephines in Keratoconic Patients Undergoing First Penetrating Keratoplasty

To investigate whether use of same-size donor and recipient trephines reduced myopia after penetrating keratoplasty for keratoconus. Retrospective cohort study. Eight hundred seventy-eight first grafts for keratoconus were reported to UK Transplant between April 1999 and December 2003. There were 234 and 644 grafts in the same-size and oversize donor trephine groups, respectively. At 1 year, mean spherical equivalent (SE) data were available for 116 eyes (50%) and 295 eyes (46%) in the same-size and oversize groups. At 2 years, mean SE data were available for 64 eyes (27%) and 148 eyes (23%) in the same-size and oversize groups. Logistic regression and univariate analysis of follow-up data submitted to UK Transplant. At 1 and 2 years postoperatively, mean SE, magnitude of the cylindrical component of the refraction, postoperative uncorrected visual acuity (VA), postoperative best-corrected VA, and postoperative complications were recorded. The mean SEs for the same-size and oversize donor trephine groups, respectively, were -1.45 diopters (D) and -1.41 D at 1 year (P = 0.6) and -1.74 D and -2.19 D at 2 years postoperatively (P = 0.3). Although there were no differences in graft survival between the groups at 1 and 2 years, there was a higher incidence of postoperative wound leaks in the same-size group (P = 0.03). Use of same-size donor and recipient trephines did not reduce myopia and was associated with an increased risk of postoperative complications.

Three-Dimensional Spectral Domain Optical Coherence Tomography of a Clear Corneal Cataract Incision

A prototype 1,310-nm wavelength spectral domain optical coherence tomography (SD-OCT) instrument was constructed and mounted onto a conventional slit lamp for imaging of the anterior segment. The device had an axial resolution of 8 microm and was able to acquire real-time two-dimensional images at 14 frames/second and full three-dimensional datasets in approximately 7 seconds. An SD-OCT dataset of 100 B-scans, each consisting of 512 A-scans, was acquired from the left eye ofa patient who had undergone phacoemulsification with a clear corneal incision. The resulting dataset could be manipulated in three-dimensional space to analyze the geometry of the wound. Additionally, stromal edema and iris features were clearly imaged with the device. SD-OCT can be used to analyze clear corneal incisions to determine optimal wound construction technique and geometry as they relate to the prevention of complications such as postoperative wound leak, infection, and epithelial ingrowth.

The Clear Corneal Tongue: A Mechanism for Wound Incompetence After Phacoemulsification

To describe a mechanism for wound incompetence after phacoemulsification with corneal incisions resulting in early postoperative wound leakage. Observational case series. Three patients who had uneventful phacoemulsification through a clear corneal incision were identified because of a postoperative wound leak. A corneal tongue, consisting of an everted triangular flap of posterior corneal stroma, the Descemet membrane, and endothelium, was observed in the wounds of all cases. One wound leak resolved after pressure patching. The other two necessitated wound revisions. None of the patients developed endophthalmitis. In phacoemulsification with corneal incisions, an everted flap of posterior corneal tissue, a corneal tongue, may prevent normal anatomical apposition of the surgical wound edges leading to potential wound incompetence. This event may increase the risk of endophthalmitis after clear corneal phacoemulsification.

Review of consecutive phacotrabeculectomies supplemented with early needle revision and antimetabolites

Background: To describe the results of a novel postoperative management approach for patients undergoing combined cataract and glaucoma surgery supplemented with early needle revision and antimetabolites. Methods: Consecutive retrospective chart review identified 66 patients who had undergone combined cataract and glaucoma surgery with early needling and antimetabolite injections between January 2002 and May 2003; 8 patients were excluded from analysis because of missing data or inadequate follow-up time. Single-site phacotrabeculectomy was performed followed by subconjunctival antimetabolite injections of 5-fluorouracil (5-FU). Needling was performed as an office procedure if early evidence of subconjunctival scarring was observed 2–6 weeks after surgery. Additional subconjunctival 5-FU injections were administered after needling, and repeat needling was performed with 5-FU or mitomycin-C if subconjunctival scarring recurred. A complete success was defined as a reduction in intraocular pressure (IOP) to <18 mm Hg without the use of antiglaucoma medications or further surgical procedures to control IOP. The outcome was considered a qualified success when antiglaucoma medications were required to achieve the same result. Results: The mean preoperative IOP was 21.9 (SD 6.3) mm Hg, and the mean postoperative IOP at 6 months was 13.0 (SD 6.7) mm Hg. The mean number of medications was reduced from 2.9 (SD 1.3) preoperatively to 0.5 (SD 0.9) postoperatively at 6 months. Needling was performed because of early evidence of subconjunctival scarring in 34 patients. The 6-month outcomes of 37 patients (64%) were a complete success and of 47 patients (81%) were a complete or qualified success. A longer follow-up of 10–23 months was attained in 25 of the 58 patients. At latest visit, the mean postoperative IOP of this group was 13.0 (SD 5.5) mm Hg, the mean number of postoperative medications was 0.7 (SD 1), and 21 of the 25 (84%) had achieved a complete or qualified success. The most common complication for all 58 patients was an early, self-limited postoperative wound leak that was unrelated to the needling intervention and was observed in 26 patients (45%). Interpretation: Phacotrabeculectomy supplemented with early needle revision and antimetabolites may improve outcomes of combined cataract and glaucoma surgery.

Prognosis and risk factors for early postoperative wound leaks after trabeculectomy with and without 5-Fluorouracil

PURPOSE: To evaluate the prognosis of patients who develop early postoperative wound leaks after trabeculectomy, to determine risk factors for these leaks, and to document adverse outcomes. DESIGN: Multicenter randomized clinical trial. METHODS: Two-hundred thirteen patients with previous cataract surgery or failed filtering surgery were randomized to either trabeculectomy (standard group) or trabeculectomy with postoperative subconjunctival 5-fluorouracil injections (5-FU group). Masked measurements of intraocular pressure were performed throughout 5 years of follow-up. Failure was defined as a reoperation to control intraocular pressure or an intraocular pressure greater than 21 mm Hg with or without medication at or after the 1-year examination. An early postoperative wound leak was defined as one that developed within 2 weeks postoperatively, determined by daily topical fluorescein testing. RESULTS: At 1 year (5 years), the success rate for the 5-FU group was 80% (54%) in eyes without a leak, and 60% (28%) in those with a leak. The 1-year (5-year) success rate in the standard group was 50% (24%) in those without a leak and 44% (15%) with a leak. ( P = .018, log-rank test, adjusted for treatment). Leaks were more common in the 5-FU group, 34/105 (32%), than in the standard treatment group, 22/108 (20%), ( P = .066, χ 2). More eyes with one-layer conjunctiva-Tenon capsule closure developed leaks 40/115 (35%) than those with two-layer closure 16/95 (17%) ( P = .006, χ 2). More eyes with a trabeculectomy located inferiorly 29/76 (38%) developed leaks than those done superiorly 27/137 (20%) ( P = .006, χ 2). Patients with leaks were older (66 years) than those without leaks (60 years) ( P = .011, t test). CONCLUSION: An early postoperative wound leak was a risk factor for trabeculectomy failure. We recommend that trabeculectomy be performed in a superior location with a two-layer closure.

The use of the same size host and donor trephine in penetrating keratoplasty for keratoconus.

The results of a retrospective analysis of 49 eyes (40 patients) that underwent penetrating keratoplasty for keratoconus are presented. All grafts had the same size trephine for both host and donor corneas. Ninety-eight per cent of eyes achieved a post-operative visual acuity of 6/12 or better; 43% of eyes attained this level of acuity unaided, although more than half of these required spectacles or contact lenses to reach their best corrected acuity. The average post-operative spherical ametropia was -0.5 dioptre (SD 2.97 dioptres) and the average post-operative cylinder was -3.8 dioptres (SD 2.63 dioptres). Three eyes (6%) required keratorefractive surgery to reduce astigmatism. Wound integrity was satisfactory using the same (size) trephine for both host and donor, with no patient suffering a post-operative wound leak or iris prolapse. The reduction of post-operative myopia and astigmatism is discussed.

Cyanoacrylate Adhesive Closure of Wound Leaks Following Fornix-Based Trabeculectomy with Adjunct 5-Fluorouracil

Conjunctival wound leaks in the early postoperative period present a significant management problem following trabeculectomy with 5-fluorouracil (5-FU). Twelve patients who developed persistent leaks in fornix-based conjunctival flaps were treated with cyanoacrylate adhesive and a bandage contact lens. Injections of 5-FU were continued with the adhesive in situ in all of these patients. The combination of adhesive and 5-FU injections did not appear to interfere with conjunctival healing, but corneal epithelial and/or conjunctival changes were observed in all patients who received three or more adhesive applications. With a mean follow up of 11.4 ($pM3.4) months, nine patients (75%) were considered clinical successes. Mean intraocular pressure was 12.4 ($pM5.8) mm Hg in the successful group. Persistent postoperative wound leaks can therefore be managed with cyanoacrylate adhesive as an alternative to resuturing, and 5-FU therapy can be continued under close observation with the adhesive in place.