Prior Corneal Surgery Research Articles

Clinical Characteristics and Outcomes of Fungal Keratitis in the United Kingdom 2011-2020: A 10-Year Study.

Fungal keratitis (FK) is a serious ocular infection that often poses significant diagnostic and therapeutic dilemmas. This study aimed to examine the causes, clinical characteristics, outcomes, and prognostic factors of FK in the UK. All culture-positive and culture-negative presumed FK (with complete data) that presented to Queen’s Medical Centre, Nottingham, and the Queen Victoria Hospital, East Grinstead, between 2011 and 2020 were included. We included 117 patients (n = 117 eyes) with FK in this study. The mean age was 59.0 ± 19.6 years (range, 4–92 years) and 51.3% of patients were female. Fifty-three fungal isolates were identified from 52 (44.4%) culture-positive cases, with Candida spp. (33, 62.3%), Fusarium spp. (9, 17.0%), and Aspergillus spp. (5, 9.4%) being the most common organisms. Ocular surface disease (60, 51.3%), prior corneal surgery (44, 37.6%), and systemic immunosuppression (42, 35.9%) were the three most common risk factors. Hospitalisation for intensive treatment was required for 95 (81.2%) patients, with a duration of 18.9 ± 16.3 days. Sixty-six (56.4%) patients required additional surgical interventions for eradicating the infection. Emergency therapeutic/tectonic keratoplasty was performed in 29 (24.8%) cases, though 13 (44.8%) of them failed at final follow-up. The final corrected-distance-visual-acuity (CDVA) was 1.67 ± 1.08 logMAR. Multivariable logistic regression analyses demonstrated increased age, large infiltrate size (>3 mm), and poor presenting CDVA (<1.0 logMAR) as significant negative predictive factors for poor visual outcome (CDVA of <1.0 logMAR) and poor corneal healing (>60 days of healing time or occurrence of corneal perforation requiring emergency keratoplasty; all p < 0.05). In conclusion, FK represents a difficult-to-treat ocular infection that often results in poor visual outcomes, with a high need for surgical interventions. Innovative treatment strategies are urgently required to tackle this unmet need.

Twenty-Four-Month Outcome of Gonioscopy-Assisted Transluminal Trabeculotomy (GATT) in Eyes With Prior Corneal Transplant Surgery.

Glaucoma is a well-known sequelae of corneal transplant surgery and is a leading cause of visual loss in this patient group. We evaluated the performance and safety of gonioscopy-assisted transluminal trabeculotomy (GATT) in this population. Noncomparative retrospective case series. Consecutive eyes of patients receiving the GATT procedure for uncontrolled intraocular pressure (IOP) following corneal transplant surgery from 2016 to 2019. Retrospective analysis of eyes with a history of prior corneal transplant undergoing GATT at Glaucoma Associates of Texas between 2016 and 2019 was performed. Data included IOP, patient demographics, preoperative and postoperative medications, preoperative and postoperative corneal procedures, complications, and need for reoperation for IOP control. IOP reduction and medication use following the procedure. Thirty-nine eyes of 32 patients with prior corneal transplant surgery underwent a GATT procedure. Prior corneal surgery included penetrating keratoplasty (59.0%), Descemet's stripping endothelial keratoplasty (35.9%), Descemet's membrane endothelial keratoplasty (2.6%), and deep anterior lamellar keratoplasty (2.6%). Patient age ranged from 24 to 94 years (mean 68.0 y) with 44% female and 81% Caucasian. The majority of patients had secondary open angle glaucoma (64.1%). There was a significant reduction in IOP and number of medications at all postoperative time points after censoring patients requiring reoperation to control IOP (P<0.001). At 24 months the pressure decreased from baseline of 30.9±11.5 to 13.9±4.7 mm Hg. Medications decreased from 4.2±1.0 medications at baseline to 0.6±1.0 at 24 months. Visual acuities decreased significantly over the first postsurgical month (all P<0.05), but these recovered at subsequent follow-up visits with 2-Snellen line improvements exceeding losses from month 3 to 36. Seven eyes required reoperation for uncontrolled glaucoma at a median of 8.5 months (range: 1.6 to 16.2 mo) after GATT. The cumulative proportion of eyes undergoing repeat cornea surgery was 2.6%, 2.6%, and 14.3% at 12, 24, and 36 months post-GATT, respectively. This case series describes a group of glaucoma patients, with a history of prior corneal surgery, that were safely and successfully treated with GATT. While classically traditional glaucoma surgeries are considered the standard of care for eyes following corneal transplant surgery, GATT should be considered as a reasonable, safe and effective alternative for surgically lowering IOP.

Comparison of Simulated and True Keratometry Measurements Using Swept-Source Optical Coherence Tomography and Dual Scheimpflug-Placido Imaging.

Purpose To compare simulated and total keratometry and corneal astigmatism values between the IOLMaster 700 and Galilei G4 devices. Methods A retrospective chart review was conducted for all patients undergoing phacoemulsification by a single surgeon (RTP) from March through September 2020 and who underwent imaging with both the IOLMaster 700 and Galilei G4. Exclusion criteria were prior corneal surgery, keratectatic diseases and inability to obtain a reliable image during image acquisition. Mean, flat, and steep keratometry values as well as astigmatism magnitude were compared. Results A total of 200 eyes of 100 patients were included. Intraclass correlation coefficients (ICC) were moderate or high for all variables. Mean difference ± SD in SimK and TrueK between devices (G4-IOLM) was 0.05 ± 0.318 diopters and −1.1156 ± 0.438 diopters, respectively (p < 0.05 for both). The IOLM measured steeper TrueK value than the G4. For SimK, there was a statistically significant difference between devices only for mean keratometry (K), whereas for TrueK, there were significant differences in flat K, steep K, and mean K. Astigmatism analysis revealed a difference in mean (±SD) SimK of 0.07 (±0.57) D at 94 degrees and in mean TrueK of 0.04 (±0.85) D at 108 degrees. Conclusion Though there is overall good correlation between the IOLMaster 700 and Galilei G4 in SimK and astigmatism measurements, there is a significant difference in TrueK measurements, with the IOLM measuring steeper values by about 1.0 diopter as compared to the G4.

Safety and Efficacy of Scleral Lenses for Keratoconus.

SIGNIFICANCEThis study affirms the long-term safety and efficacy of scleral contact lens use in patients with keratoconus.PURPOSEThis study aimed to evaluate the safety and efficacy of contemporary scleral contact lenses in the visual rehabilitation of the keratoconic population.METHODSA retrospective study of keratoconic subjects examined between 2013 and 2018 was conducted. Subjects were included regardless of age, sex, pre-existing morbidity, or scleral lens design. Only eyes fit successfully with scleral contact lenses for ≥1 year were included. Exclusion criteria were prior corneal surgery, dystrophy, degeneration, and trauma.RESULTSA total of 157 eyes of 86 subjects met the study criteria. The mean Keratoconus Severity Score at initial fitting was 3.6 ± 1.0. Lenses were gas-permeable and nonfenestrated, with a mean overall diameter of 15.8 ± 0.6 mm and 70.1% toric scleral periphery. Physiological adverse events occurred in 9.6% of eyes, including microbial keratitis (0.6%), phlyctenulosis (0.6%), corneal abrasion (1.3%), contact lens–induced acute red eye (1.3%), corneal infiltrative events (1.3%), pingueculitis (1.3%), and hydrops (3.2%). Lens-related adverse events were documented in 55.4% of eyes. Adverse events related to surface issues included poor wetting in 1.9%, handling in 3.8%, reservoir fogging in 7.0%, lens intolerance in 7.6%, deposit in 8.9%, and broken lenses in 26.1% of eyes. The most common management strategies involved refits (54.0% of interventions), patient reeducation (29.5%), medical treatment (5.5%), surgical referral (6.8%), adjustment to wear time (2.5%), surface treatment (1.2%), and lens replacement (0.6%). Best-corrected distance logMAR visual acuity improved significantly from a mean of 0.50 in spectacles to a mean of 0.08 in scleral lenses (P < .0001). During the study period, 14.6% of eyes lost best-corrected scleral lens visual acuity, all from keratoconus progression.CONCLUSIONSConsistent with other groups, our study demonstrates excellent safety and efficacy of scleral contact lenses in subjects with keratoconus.

Influence of corneal diameter on surgically induced astigmatism in small-incision cataract surgery

ObjectiveClear corneal incisions (CCI) in cataract surgery create a variable amount of surgically induced astigmatism (SIA). As refractive outcomes become increasingly important, it is necessary to understand factors that impact SIA and refractive surprises. In this study, we evaluate the effect of horizontal corneal diameter (white-to-white, WTW) on SIA in 2.2 mm small-incision cataract surgery. DesignProspective study at an academic-university-based outpatient clinic (Duke Eye Center). ParticipantsWe enrolled adults ≥18 years of age without prior corneal surgery or corneal pathology undergoing cataract surgery with a single surgeon (R.R.V.). MethodsAll surgeries were uncomplicated and performed through a manually constructed, limbal, temporal, or superotemporal 2.2 mm CCI. Enrolled participants received standard-of-care evaluations and postoperative management. SIA was calculated at the first postoperative month using the Jaffe and Clayman vector analysis equation. ResultsWe enrolled 43 subjects (55 eyes) with a mean age of 71 years with WTW corneal diameter values ranging from 11.34 to 12.99 mm obtained from Lenstar® (Haag-Streit Group, Koeniz, Switzerland). Postoperative SIA ranged from 0.072 to 1.6 D (mean 0.47 D, standard deviation 0.33 D). SIA was plotted against WTW and best fit to a linear regression model with a slope of −0.056 and an R2 value of 0.006. ConclusionsIn this prospective study, WTW diameter had minimal effects on the SIA in uncomplicated small-incisional cataract surgery through a 2.2 mm temporal or superotemporal CCI with a single surgeon. Our findings suggest that corneal diameter does not play a clinically significant role in this population undergoing small-incisional cataract surgery.

Corneal clarity after Descemet membrane endothelial keratoplasty versus Descemet stripping endothelial keratoplasty: Two‐year outcomes

PurposeTo compare the course of Scheimpflug corneal densitometry (CD) after Descemet membrane endothelial keratoplasty (DMEK) versus Descemet stripping automated endothelial keratoplasty (DSAEK) versus age‐matched controls.MethodsFrom two consecutive series of 130DMEKand 49DSAEKcases, 54DMEKand 25DSAEKcases without prior corneal surgery, complicated intraoperative or postoperative course or vision‐limiting ocular comorbidities were included in this study. Pseudophakic eyes of age‐matched subjects were recruited as controls (n=20). ScheimpflugCDof the optically relevant zones (0‐2 mm and 2‐6 mm), best‐corrected visual acuity (BCVA) endothelial cell density (ECD) and central corneal thickness (CCT) were evaluated preoperatively and at 3, 6, 12 and 24 months postoperatively.ResultsCDwas significantly lower afterDMEKat 3 and 6 months compared toDSAEK(P≤0.012). The two groups reached similar levels ofCDat 12 and 24 months after surgery (P≥0.056). Compared to healthy pseudophakic controls, centralCDat 24 months afterDMEKdid not differ significantly (P=0.152). PostoperativeBCVAwas significantly higher afterDMEKfor every examination time point compared toDSAEK(P&lt;0.001).ECDwas similar in both groups (P≥0.081).ConclusionsThe first 6 postoperative monthsCDwas lower andBCVAhigher afterDMEKcompared toDSAEK. Notably, althoughCDreached similar levels in the midterm after bothDMEKandDSAEK,BCVAremained significantly better afterDMEK. Two‐yearCDafterDMEKwas similar toCDof healthy pseudophakic eyes indicating an excellent restoration of corneal clarity in the midterm.

Mycotic Keratitis, a State-of-the-art Review

: Microbial corneal diseases are a serious ocular infection and the major cause of ocular morbidity and blindness in the world. The outcomes of fungal keratitis are unfavorable due to the protracted course of the condition and the diversity of respective clinical presentations. Trauma, contact lens wear, foreign material, and prior corneal surgery, may make the most background for permitting invasion by exogenous fungi by injecting the fungal conidia directly in the corneal stroma. Other risk factors consist of blocked naso-lacrimal duct, and ocular surface disease. More than 105 species of fungi, such as Aspergillus spp., Fusarium spp., Candida spp., Rhizopus, Mucor, and other fungi have been identified as the etiological agents of fungal keratitis. The first step of diagnosis begins with clinical suspicion, followed by corneal scrapings or biopsy for direct smear and culture confirming the etiological agent. Slit lamp biomicroscope is used for careful examination of the infected eye and pictorial documents like the ulcer size, site, depth, extent of infiltration, abscess formation, and any perforation are evaluated. Direct smears are prepared by potassium hydroxide wet mount, or Gram’s staining. To identify the isolates, a lactophenol cotton blue wet mount is prepared, and diagnosis is based on morphology of the culture media and details of microscopic examination. The results are highly specific but have suboptimal sensitivity varying in different studies. Molecular assays are valuable for the diagnosis of fungal keratitis in patients. Various advantages and limitations are reported for such methods. Overall, PCR is a sensitive and promising tool for the diagnosis of fungal keratitis but the expertise required and the lack of sophisticated facilities renders it inferior to the smear techniques in routine laboratory procedures and is not recommended accordingly. Rapid diagnosis and proper treatment are essential for fungal keratitis, and many patients require several months of therapy until the infiltrate is resolved and epithelial stroma are healed. Patients not responsive to antifungal therapy usually require corneal transplantation.

Kératites bactériennes sévères reçues aux urgences ophtalmologiques : analyse rétrospective de 268 cas

To investigate epidemiological, microbiological and clinical aspects of severe bacterial keratitis, in order to update current understanding of risk factors (RF) and prognosis. We conducted a monocentric retrospective study from January 2005 to January 2011, identifying and collecting data from inpatients admitted for severe documented bacterial keratitis. We found 268 unilateral corneal ulcers. At least one local or systemic risk factor was identified in 255/268 patients (95%). The leading risk factor was contact lens wear (129/268), followed by underlying corneal disease (50/268) and prior corneal surgery (47/268). Initial and final visual acuities were 0.06 and 0.2 (1.20 and 0.72 LogMAR) respectively. Contact lens wear was associated with better prognosis and shorter hospitalization (P<0.05). Corneal healing was obtained in 255/268 patients (95%), with adjuvant surgery for 33 patients. The most frequently isolated pathogens were Gram+ cocci, more commonly associated with degenerative keratopathy or prior corneal surgery, and Gram- bacilli, more commonly associated with contact lenses (P<0.05). Both demonstrated a similar prognosis. Specific risk factors should be investigated in cases of severe bacterial keratitis. Contact lens wear is the most frequent risk factor, but with a better prognosis than underlying corneal disease, prior corneal surgery or systemic risk factors. The specific bacterial pathogen no longer appears to dramatically influence the outcome of severe corneal ulcers.

Mooren’s ulcer

Mooren’s ulcer (MU) is an inflammatory peripheral ulcerative keratopathy that occurs most commonly in the developing world. Recent evidence supports the notion that autoimmune mechanisms are involved in the pathogenesis of this disease. Patients with MU typically develop painful, progressive peripheral ulceration of the cornea that, if untreated, can lead to corneal perforation and blindness. Risk factors for the development of MU include HLA-DR17 haplotype expression, prior corneal surgery or trauma, and hookworm infestation. A thorough ocular and systemic history and clinical examination, together with directed laboratory testing, should be carried out to rule out other causes of corneal ulceration, including both infectious keratitis and peripheral ulcerative keratitis secondary to an underlying systemic autoimmune disease. Treatment of MU is often challenging, but typically includes local and/or systemic corticosteroids. Noncorticosteroid immunosuppressive agents, conjunctival resection or advancement and tectonic surgical repair have also been used with success in patients refractory to corticosteroid therapy.

The Boston Type I Keratoprosthesis: Improving Outcomes and Expanding Indications

To report the usefulness of the Boston type I keratoprosthesis (Massachusetts Eye and Ear Infirmary, Boston, MA) in the management of corneal opacification, corneal limbal stem cell failure, or both in a large single-surgeon series. Retrospective review of consecutive clinical case series. All patients undergoing keratoprosthesis implantation by a single surgeon (AJA) between May 1, 2004, and May 31, 2008. Data were collected regarding the preoperative characteristics of each eye undergoing keratoprosthesis implantation, the surgical procedure(s) performed, and the postoperative course. Statistical analysis was performed to identify factors influencing the incidence and severity of postoperative complications. Interval visual acuities, keratoprosthesis retention, and significant postoperative complications. Fifty-seven keratoprosthesis procedures were performed in 50 eyes of 49 patients. The primary indication for surgery was repeat corneal transplantation failure (68%), although no prior corneal surgery had been performed in 16% of eyes. Preoperative visual acuity was 20/200 or worse in all eyes, with 88% of eyes having preoperative vision of counting fingers, hand movements, or light perception. The percentage of eyes with postoperative visual acuity of 20/100 or better was 67% at 6 months (n = 45), 75% at 1 year (n = 28), 69% at 2 years (n = 13), and 100% at 3 years (n = 7). In the 31% of patients in whom preoperative vision in the contralateral eye was 20/50 or better, the postoperative vision in the operative eye improved to 20/50 or better in 47% at the last follow-up (average, 18 months; range, 4-49 months). The overall keratoprosthesis retention rate was 84% at an average follow-up of 17 months (79 person-years of follow-up), with 100% retention in 8 eyes with no history of prior corneal transplantation (14.8 person-years of follow-up). The most common postoperative complications were retroprosthetic membrane formation (22 eyes) and persistent epithelial defects (19 eyes). No cases of infectious endophthalmitis were encountered, and only 1 patient with a history of glaucoma required additional glaucoma surgery during the postoperative period. The Boston type I keratoprosthesis is an effective means of managing repeat corneal graft failure and corneal limbal stem cell failure with or without corneal opacification in patients with both unilateral and bilateral visual impairment.

Microbial Keratitis in Childhood

Microbial keratitis occurs infrequently in childhood. The leading ocular predisposing factors are trauma and preexisting corneal disease. Many of the age-related risk factors in adults play a minor role in children. The authors retrospectively studied 51 eyes with ulcerative keratitis in 50 children younger than 16 years of age. This includes all patients treated at Bascom Palmer Eye Institute during an 11 1/2-year period from January 1, 1980, to June 30, 1991. The criterion for inclusion in the study was a discharge diagnosis of microbial (nonviral) keratitis. The principal risk factors identified in this study were trauma (44%), prior corneal surgery (24%), systemic illness (14%), and contact lens wear (12%). Systemic illness or an immunocompromised state existed in 7 (47%) of the 15 children younger than 3 years of age. There was a large male preponderance (68%). Forty-four (86.3%) of the 51 eyes were culture-positive; six (11.7%) were polymicrobial. Five of seven culture-negative patients had received prior topical antibiotic therapy. Pseudomonas aeruginosa (34%), Staphylococcus aureus (20%), and fungi (18%) were the most common organisms isolated. Seven (14%) eyes required surgery. This study presents important differentiating factors between adult and childhood nonviral microbial keratitis. Identification of principal risk factors in children may aid in early recognition and treatment of microbial keratitis.