Rate Of Endothelial Cell Loss Research Articles

Outcomes of cataract surgery in eyes with a low corneal endothelial cell density

To evaluate the surgical outcomes of cataract surgery in eyes with a low preoperative corneal endothelial cell density (ECD) and analyze factors affecting the prognosis. Tokyo Dental College, Ichikawa General Hospital, Chiba, Japan. Noncomparative case series. Eyes with a preoperative ECD of less than 1000 cells/mm(2) that had cataract surgery between 2006 and 2010 were identified. Standard phacoemulsification with intraocular lenses was performed using the soft-shell technique. The rate of endothelial cell loss, incidence of bullous keratopathy, and risk factors were retrospectively assessed. Sixty-one eyes (53 patients) with a low preoperative ECD were identified. Preoperative diagnoses or factors regarded as causing endothelial cell loss included Fuchs dystrophy (20 eyes), laser iridotomy (16 eyes), keratoplasty (10 eyes), traumatic injury (3 eyes), trabeculectomy (3 eyes), corneal endotheliitis (2 eyes), and other (7 eyes). The corrected distance visual acuity improved from 0.59 ± 0.49 logMAR preoperatively to 0.32 ± 0.48 logMAR postoperatively (P<.001). The mean ECD was 693 ± 172 cells/mm(2) and 611 ± 203 cells/mm(2), respectively (P=.001). The mean rate of endothelial cell loss was 11.5% ± 23.4%. Greater ECD loss was associated with a shorter axial length (AL) (<23.0 mm) and diabetes mellitus. Bullous keratopathy developed in 9 eyes (14.8%) and was associated with posterior capsule rupture. The results suggest that modern techniques for cataract surgery provide excellent visual rehabilitation in many patients with a low preoperative ECD. Shorter AL, diabetes mellitus, and posterior capsule rupture were risk factors for greater ECD loss and bullous keratopathy.

Graft survival and endothelial outcomes in the new era of endothelial keratoplasty

Corneal endothelial cells do not proliferative in vivo sufficiently to enable endothelial regeneration, and thus diseases of the corneal endothelium, which cause poor vision and discomfort, require treatment by transplantation of cadaveric donor corneal endothelial cells. The two major goals of any corneal transplant procedure are to restore vision and to promote longevity of the donor cornea by maintaining a healthy donor endothelial cell density. Over the last decade, the surgical treatment for endothelial disease has rapidly evolved toward endothelial keratoplasty, or selective tissue transplantation, and away from full-thickness penetrating keratoplasty (PK). While endothelial keratoplasty offers distinct advantages over PK in terms of visual outcomes and a smaller incision, the new surgical manipulations of the fragile donor tissue cause significant donor endothelial cell trauma. As a result, donor endothelial cell loss is much higher during the first month after Descemet stripping endothelial keratoplasty (DSEK) compared to after PK, and the primary (or more appropriately, iatrogenic) graft failure rate of 5% remains unacceptably high. Nevertheless, the rate of endothelial cell loss rapidly decreases beyond 6 months after DSEK, and thus endothelial cell loss at 5 years after DSEK appears to be lower than that at 5 years after PK. In the absence of primary (iatrogenic) graft failure, graft survival through 5 years after DSEK is similar to that after PK. Given the promising longer-term endothelial outcomes of DSEK, the quest for optimizing the visual outcomes has spurred interest in Descemet membrane endothelial keratoplasty (DMEK). While early results after DMEK suggest better visual outcomes than after DSEK, the technique needs to be simplified, and longer-term outcomes must show an advantage over DSEK with respect to vision, endothelial cell loss, and graft survival. DMEK also has a high rate of primary (iatrogenic) graft failure, and additional donor tissue wastage occurs when preparation of DMEK grafts is unsuccessful. This review discusses endothelial keratoplasty techniques and the associated endothelial outcomes.

The application of burst and soft shell techniques in phacoemulsification for complicated cataract

Objective To discuss the clinical effect of burst technique and soft shell technique in phacoemulsification on complicated cataract. Methods Totally 38 cases (45 eyes) of complicated cataract were observed. The cataract were characterized as post-antiglaucoma surgery,hard nucleus of degree Ⅳ～ degree Ⅴ, and corneal endothelial cell counting less than 1500/mm2. Burst pattern was used in phacoemulsification,and soft shell technique was used for protecting endothelial cell during the surgery. The power,effect phaco time and cumulative compound power parameter were recorded. A control group of 38 cases (45 eyes)was made with pulse technique in Phaco. The vision, corneal edema, dense of corneal endothelial cell and complications were observed. Results The effect phaco time of experimental group was (22.44 ± 13.24) s,with an actual phaco power of ( 14.37 ± 5.84) % and cumulative compound power parameter of (353.26 ±306.88). The va; ie pf cpmtrp; group was ( 79.02 ± 38.29 ) s, ( 25.44 ± 8. 34 ) % and ( 2402.97 ±2296.61 ) respectively. There were statistically significant difference ( P ＜ 0. 01 ). The cornea edema of experimental group was degree 0 to degree 2 one day postoperatively. The rate of corneal endothelial cell loss was 9.35% one month after surgery. There was no statistically significant difference between the preoperative one and the postoperative one (P ＞0.05 ). That of control group was degree 0 ～ degree 3 and 31. 19% postoperatively,which was significantly different from the preoperative one (P ＜0. 01 ). Conclusion The technique of burst and soft shell could decrease intraocular injury and improve the surgery outcome. Key words: phacoemulsification; burst; soft shell; complicate cataract

Safety of Moxifloxacin and Voriconazole in Corneal Storage Media on Porcine Corneal Endothelial Cells

The aim of this study was to evaluate the safety of moxifloxacin and voriconazole as a supplement in corneal storage media for porcine corneal endothelial cells. Twenty-eight eyes were divided into 4 groups. In the control group (the C group), corneal buttons were stored for 3 days in Optisol-GS. In the treatment group, the corneal buttons were preserved for 3 days in Optisol-GS mixed with 250 microg/mL moxifloxacin (M group), 100 microg/mL voriconazole (V group), and 250 microg/mL moxifloxacin plus 100 microg/mL voriconazole (MV group). We evaluated the samples via specular microscopy before and after 3 days of preservation. The mean changes of endothelial cell counts were compared among the 4 groups. Scanning electron microscopy was conducted after 3 days of preservation. Before the preservation, the endothelial cell counts did not differ among the 4 groups (P > 0.05). After 3 days of preservation, the endothelial cell count in the MV group was the lowest among the 4 groups (P < 0.05). After 3 days of preservation, the rate of corneal endothelial cell loss in the M and V groups did not differ significantly from the control group (P > 0.05). The rate of endothelial cell loss in the MV group was significantly higher than that of the control group (P < 0.05). Scanning electron microscopy revealed a normal mosaic pattern for the C, V, and F groups, but hexagonality was not preserved in the MV group. Preservation in Optisol-GS mixed with moxifloxacin (250 microg/mL) plus voriconazole (100 microg/mL) induced significant toxicity on the endothelial cells in porcine corneas, when compared with the control group.

A New Method of Harvesting Descemet Membrane-Endothelium Complex Approaching From the Suprachoroidal Space for Descemet Membrane Endothelial Keratoplasty: An Experimental Animal Study

To report the study in rabbits of a new method of harvesting Descemet membrane-endothelium complex approaching from the suprachoroidal space for Descemet membrane endothelial keratoplasty. Twenty-four eyes of 12 rabbits were used for microscopic analysis, whereas 24 eyes of 12 cats were used for gross photographic analysis. The enucleated eyeballs of the rabbits and cats were incised 360 degrees circumferentially along the equator. Manual separation was performed between the sclera and the underlying connective tissue approaching from the suprachoroidal space in the direction of the central cornea step by step in spiral pattern. After complete separation of the stroma from the Descemet membrane-endothelium-iris complex, it was excised from the globe at the outside of the iris root. The synthetic carrier (soft contact lens) was laid down on the punch block, and then the excised complex was brought over the carrier with the endothelium-iris side upward. Two steps of down punch for the designed graft size were performed. The harvested complexes were processed for vital stains and were evaluated through photography taken under a light microscope and gross close-up. The endothelial cell loss rates were calculated by a computer software. The overall harvest success rate was 89.6% (43 of 48). The overall structural cell loss rate was 1.83 +/- 2.34 by microscopic analysis and 4.68% +/- 1.68% by gross photographic analysis. The new method of en bloc harvesting Descemet membrane-endothelium complex approaching from the suprachoroidal space could provide minimal damage to the endothelium during harvesting, and it can be carried and passed through an injector.

Bimanual microincision phacoemulsification in treating hard cataracts using different power modes

To compare the performance of the Multiburst mode, the Shortpulse mode and the Whitestar technology of the Sovereign platform in treating hard cataracts with bimanual microincision phacoemulsification. 101 eyes with hard cataracts (nuclear density Grade 3 and Grade 4 or above) were randomized into three groups. Bimanual microincision phacoemulsification was performed using the Multiburst mode, the Shortpulse mode and the Whitestar technology of the Sovereign phacoemulsification machine respectively. The average power, total duration of ultrasonic power release (US Time), effective phaco time, complications, best-corrected visual acuity and rate of corneal endothelial cell loss were measured and compared among the study groups. For hard cataracts of various nuclear densities, average ultrasonic power was highest in the Whitestar group followed by the Shortpulse group. The Multiburst group had the highest US Time, effective phaco time and rate of corneal endothelial cell loss whereas the Whitestar Group had the lowest.The differences between the groups were found to be statistically significant by variation analysis and the Fisher's least significant difference procedure. However, there were no significant differences between the USTime values of the Shortpulse Group and the Whitestar Group (P = 0.051). In the Multiburst Group, wound burn occurred in one eye, and three eyes had abnormal fluctuations in the anterior chamber depth. The Whitestar technology showed the best performance in this study.The Multiburst mode was proved to be a relatively unsuitable ultrasonic power mode in treating hard cataracts with bimanual microincision phacoemulsification.

Prospective Long-term Evaluation of the Efficacy, Safety, and Stability of the Phakic Intraocular Lens for High Myopia

To evaluate the safety, efficacy, predictability, and long-term stability of the Artisan Phakic Intraocular Lens (Ophtec BV, Groningen, the Netherlands) for the correction of high myopia. Prospective analysis of 26 eyes from 15 patients who underwent placement of the Artisan lens for the correction of high and extreme myopia. The mean (SD) preoperative spherical equivalent was - 12.30 (2.69) diopters (D) (range, - 17.25 to - 8.25 D). At 5 years, the mean (SD) manifest refraction was - 0.37 (0.69) D, with 95% of eyes within 1 D of attempted correction and 74% of eyes within 0.5 D of the attempted correction. Ninety-five percent of eyes achieved an uncorrected visual acuity of 20/40 or better and 74% achieved an uncorrected visual acuity of 20/20 or better. No eyes experienced a loss of 1 or more lines of best-corrected visual acuity. Sixteen percent of eyes gained 2 or more lines of best-corrected visual acuity. From preoperative measurements, the mean endothelial cell density decreased by 14.05% at 5 years postoperatively. Placement of the Artisan lens is predictable, stable, and effective at reducing high and extreme myopia 5 years after implantation. The rate of endothelial cell loss was significantly higher than has been reported in previous studies.

Superior efficacy of low-molecular-weight heparin vs unfractionated heparin in acute coronary syndrome without ST elevation

To evaluate the 5-year efficacy of a foldable, hydrophobic, angle-supported phakic intraocular lens (pIOL) when used to correct moderate to high myopia.Prospective, nonrandomized, multicenter, open-label cohort study conducted in the United States, the European Union, and Canada (3 separate protocols).This was a pooled analysis of 515 eyes from 360 patients 18 to 49 years of age with moderate to high myopia (preoperative corrected distance visual acuity [CDVA] ≤0.34 logarithm of the minimum angle of resolution [logMAR]) and with variance in the manifest refraction spherical equivalent within ±0.5 diopter (D) for a minimum of 12 months.Implantation of the AcrySof Cachet angle-supported anterior chamber pIOL (Alcon Laboratories, Inc., Fort Worth, TX).Uncorrected distance visual acuity (UDVA), CDVA, predictability and stability of manifest refraction spherical equivalent (MRSE), serious adverse events, endothelial cell density, and patient satisfaction.Of 360 patients who received implantation in at least 1 eye (515 eyes), 326 (90.6%) completed the study (5-year best-corrected visual acuity data available for 415 eyes). At 5 years, a decrease in CDVA of 2 lines or more was observed in 0.5% of eyes (n = 2/415) compared with preoperative baseline. At 5 years, all 415 eyes achieved a CDVA of 0.34 logMAR or less; 91.3% (n = 379/415) had a CDVA of 0.04 logMAR or less. Mean UDVA ± standard deviation (SD) was 0.01±0.18 logMAR; 94.7% (n = 393/415) and 66.3% (n = 275/415) of eyes had a UDVA of 0.34 logMAR or less or 0.04 logMAR or less, respectively, at 5 years. Mean MRSE ± SD was −0.34±0.57 D (range,−2.50 to 1.63 D). Most eyes (89.8%; n = 371/413) had an MRSE within ±1.00 D of their target refractive error at 5 years and 67.3% (n = 278/413) were within ±0.50 D. Mean annualized central endothelial cell loss was 1.46% (90% confidence interval [CI], −1.6% to −1.3%) from 6 months to 5 years. The most common pIOL-related serious adverse event was adhesion between the cornea and the iris (synechia; n = 24). Most patients (98.1%) indicated that they would have the same pIOL implanted again.In patients with moderate to high myopia, the AcrySof Cachet angle-supported pIOL provided excellent refractive correction for up to 5 years after implantation, with a low rate of mean central endothelial cell loss. Careful patient selection is necessary to achieve optimal postsurgical outcomes.

Soft‐shell technique using Viscoat® and Healon®5: a prospective, randomized comparison between a dispersive‐viscoadaptive and a dispersive‐cohesive soft‐shell technique

To compare the efficacy of the dispersive-viscoadaptive soft-shell technique using Viscoat and Healon 5 to the dispersive-cohesive soft-shell technique in reducing corneal endothelial cell damage during cataract surgery. In this prospective randomized study, 207 eyes of 171 cataract patients underwent phacoemulsification using the dispersive-viscoadaptive soft-shell technique (V-group, 102 eyes) with Viscoat and Healon5 or the dispersive-cohesive soft-shell technique (C-group, 105 eyes) with Viscoat and a cohesive agent (Opegan-Hi). Each group was divided into two subgroups depending on the amount of ultrasound (%Min) used during phacoemulsification. Corneal endothelial cell density was examined preoperatively and 3 months postoperatively. The endothelial cell loss was compared between the two groups, and also between the subgroups. The mean endothelial cell loss 3 months after surgery was 8.4 +/- 5.6% standard deviation (SD) in the V-group and 8.2 +/- 6.2% in the C-group (P = 0.787). In the subgroups with ultrasound of 10 %Min or less, the mean endothelial cell loss 3 months after surgery was 6.6 +/- 4.6% in the V-group and 5.5 +/- 5.0% in the C-group (P = 0.104). In the subgroups with ultrasound of over 10 %Min, this value was 10.6 +/- 6.3% in the V-group and 11.9 +/- 5.7% in the C-group (P = 0.413). The correlation coefficient of the endothelial cell loss rate and %Min was 0.245 (P = 0.0129) in the V-group and 0.501 (P < 0.0001) in the C-group. The dispersive-viscoadaptive soft-shell technique is as effective as the dispersive-cohesive soft-shell technique in protecting corneal endothelial cells during phacoemulsification regardless of the amount of ultrasound energy used.

The Effectiveness and Safety of the Phaco Prechopper Technique Before Lens Phacoemulsification in Cataract Surgery

Purpose: To compare the effectiveness and safety of the phaco prechopper technique dividing lenses into 2 or 4 pieces before phacoemulsification with the effectiveness and safety of conventional phacoemulsification during cataract surgery. Methods: This study included 360 eyes, which were divided into 4 groups according to nuclear opacity each group was subdivided into 3 groups according to the lens extraction technique (control, dividing the lens into two pieces using a phaco prechopper, and dividing it into four pieces) (Table 1). The following parameters were compared between the groups that had the same degree of nuclear opacity: changes in the endothelial cell count and hexagonality 2 months postoperatively, phaco time as well as the total phaco energy used for the operation, and the complication rates. Results: There were no intra- and post-operative complications in any group. The endothelial cell loss rate was significantly less in nuclear opacity groups 2 and 3 with the prechopper technique than in the control group. Hexagonality was significantly higher in the nuclear opacity group 3 with the prechopper technique than in the control 2 months after the operation. Phaco time was significantly less in the nuclear opacity groups 2 and 3 with the prechopper technique than in the control. Total phaco energy was significantly less in the nuclear opacity groups 2, 3, and 4 with the prechopper technique than in the control. Conclusions: Phacoemulsification using the prechopper technique is safe, resulting in significantly less endothelial cell damage, and requires less phaco time and less total phaco energy compared to those of the conventional phacoemulsification technique.

PKP versus LKP: rehabilitation speed, optical performance, endothelial cell loss

AbstractThis presentation will provide a critical comparison between penetrating and lamellar keratoplasty as far as rehabilitation speed, optical performance, endothelial cell loss and immunological rejection rate is concerned.Deep anterior lamellar keratoplasty has the advantage of retaining a stronger globe and no risk of late endothelial failure, implying patients might be able to keep their graft for the rest of their life. There is also a reduced risk of graft rejection, or at least the damage caused will not be directed towards the vital endothelial cells. This however seems to go at the expense of visual acuity and quality. High postoperative astigmatism remains an issue and interface haze ‐when dissection is not down to bare Descemets‐ limits the vision to 20/40 in some cases. The decrease in recipient endothelial cell loss mimics the physiological cell loss of non operated corneas except maybe in patients with macular dystrophy.The results of deep endothelial keratoplasty (either DLEK of DSAEK) seem very promising as far as astigmatic control is concerned as there is virtually no astigmatic change induced. Vision outcome in the largest reported series of DLEK was a vision of 20/40 or better in 49% of eyes. This compared to a percentage of respectively 62% and 87% in patients with DSEK or DSAEK. Contrary to common belief endothelial rejection can still hapen in patients undergoing deep endothelial keratoplasty. DS(A)EK seems to induce more endothelial cell loss than DLEK which is probably a direct consequence of the current taco folding techniques. New insertion devices are currently developped to minimise this increased cell loss.

Long-term Follow-up of Endothelial Cell Change after Artisan Phakic Intraocular Lens Implantation

To report endothelial cell densities (ECDs) and their correlation to anterior chamber depth (ACD) after implantation of the Artisan intraocular phakic lens. Prospective observational case series. Three hundred eighteen eyes of 173 myopic patients treated with the Artisan iris-fixated phakic intraocular lens (IOL). Eyes with an ACD ranging between 2.89 and 4.5 mm were implanted with the Artisan phakic IOL. Endothelial cell density measurements were performed preoperatively and at each follow-up examination using a noncontact specular microscope. Endothelial cell density (cells per square millimeter). Follow-up ranged between 1 (82 eyes) and 7 years (13 eyes) (mean, 35.3+/-20.7 [standard deviation] months per eye). After 3 years, there was a significant loss in ECD (P< or =0.03). At 5 years, mean observed endothelial cell loss was 8.3% (5.3% corrected for a natural endothelial cell loss of 0.6% a year). Endothelial cell density loss remained progressive throughout our follow-up period. After 3 years, a significant negative correlation between ACD and endothelial cell loss was revealed (P< or =0.03). Patient age, gender, refractive error, incision size, and side of the eye were not correlated to ECD loss. All corneas remained clear throughout the study. After 3 years, a significant ECD loss was revealed. This ECD loss was significantly negatively correlated to the ACD. We therefore suggest that eyes just meeting the minimum ECD requirement have greater ACDs to compensate for possible greater endothelial cell loss and that patients with shallow anterior chambers have higher ECDs. Artisan phakic lens implantation in young eyes narrowly meeting the minimum criteria of endothelial cell density (2,000 cells/mm(2)) and ACD (2.6 mm) should perhaps be reevaluated, due to longer exposure to higher rates of endothelial cell loss.

Peripheral radial chop technique for phacoemulsification of hard cataracts

Phacoemulsification yields successful outcomes in eyes with standard cataract. Though techniques have been improved, it is still challenging to perform phacoemulsification in cases of hard cataracts for difficulty in nuclear management and much more complications. This study aimed at describing and evaluating the efficacy and safety of a peripheral radial chop technique to remove hard cataracts. In this prospective study conducted between January 2003 and January 2004, 107 consecutive eyes with hard cataract underwent modified phacoemulsification surgery with peripheral radial chop technique by the Bausch & Lomb Millennium phacoemulsifier with preset parameters of power less than 30%; vaccum, 150 mmHg; and bottle height, 85 cm when a DP8145 phaco tip was used, and vaccum, 380 mmHg; bottle height, 95 cm when a DP8245 phaco tip was used. The mean ultrasonic power was 14.7% (range 9% to 19%), ultrasonic time was 1.98 minutes (range 1.55 to 3.18 minutes). At 1, 7 and 30 days postoperatively, the eyes with uncorrected visual acuity 0.5 or better accounted for 76.42%, 87.16% and 90.67% respectively. At 1 month, the endothelial cell loss rate was 9.74% (range 8% to 17%). There were 6 cases of posterior capsule rupture in an early period of study. No serious intraoperative or postoperative complications were noted. The peripheral radial chop technique was effective without serious complications in hands of an experienced surgeon.

Risk factors for endothelial cell loss post‐keratoplasty

Transplant survival following penetrating keratoplasty is determined to a large extent by the course of endothelial cell density loss. Different influencing factors such as organ culture conditions, surgical trauma, exchange between donor and recipient cells, cell ageing and immune reactions can contribute to endothelial cell loss. The aim of this study was to determine the rate of endothelial cell loss in our patients and to detect dependencies on donor-and recipient-related factors. Using non-contact specular microscopy, endothelial cell counts were obtained every 6 months from 293 consecutive patients who underwent keratoplasty in our institution between 1996 and 2000. Follow-up time was 36 months. In comparison with the density of donor endothelial cells, the mean endothelial cell loss of patients was 28.8% after 6 months, 39.8% after 12 months and 49% after 24 months. Donor age and initial cell density did not have a significant influence on the course of endothelial cell loss. The lowest rate of endothelial cell loss was associated with patients diagnosed with keratoconus. Conversely, those with preoperative glaucoma had a significantly increased rate of endothelial cell loss (p < 0.05). This study shows that preoperative glaucoma is a major risk factor for increased endothelial cell loss following keratoplasty.

Comparison of Deep Lamellar Keratoplasty and Penetrating Keratoplasty for Lattice and Macular Corneal Dystrophies

To compare the therapeutic outcomes after deep lamellar keratoplasty (DLKP) and penetrating keratoplasty (PKP) in patients with lattice corneal dystrophy (LCD) and macular corneal dystrophy (MCD). Age-matched control study. We reviewed the clinical records of 84 eyes with LCD or MCD who had DLKP (41 eyes) or PKP (43 eyes). Primary pathology consisted of 60 eyes with LCD and 24 eyes with MCD. DLKP was performed by either removing stromal tissue gradually, or by viscodissection of Descemet's membrane. Graft clarity, best-corrected visual acuity (BCVA), endothelial density, and complications were compared between DLKP and PKP, as well as between LCD and MCD. All 84 eyes showed a postoperative improvement in visual acuity. The median final BCVA was not significantly different between PKP and DLKP groups. Endothelial cell loss rates were similar for DLKP and PKP. While the MCD-DLKP group showed progressive decrease in endothelial density, this was not observed in the LCD-DLKP group after surgery. In the DLKP group, most of the complications occurred intraoperatively or in the early phase, whereas late phase complications such as endothelial rejection and secondary glaucoma were the main complications in the PKP group. PKP is no longer an automatic choice for the surgical treatment for LCD and MCD; DLKP seems to be a safe alternative. While DLKP is a favorable method for LCD, MCD may not be a good candidate, as it might show progressive decrease in the corneal endothelium postoperatively.

Long-term follow-up of flexible open-loop anterior chamber intraocular lenses implantation

To evaluate the long-term outcome in eyes had flexible open-loop anterior chamber intraocular lens (ACIOL) implantation. Cataract extraction with primary flexible open-loop ACIOL and anterior vitrectomy were performed in 34 eyes (group I), and secondary AC IOL implantation were performed in 49 eyes (group II). Visual acuity, intraocular pressure (IOP), corneal endothelial cell, anterior chamber angle and the presence of associated complication were examined in a mean follow up of 4.8 years (range 3 to 7 years). The final best correct visual acuity was 0.5 or better in 65 eyes (78.3%). The IOP were (13.55 +/- 3.21) mm Hg preoperatively and (13.40 +/- 4.29) mm Hg (1 mm Hg = 0.133 kPa) at the last follow-up (t = 0.5427, P = 0.5888). In group I, the corneal endothelial cell density were (2497 +/- 629)/mm(2) preoperatively, while at the last follow-up it was (1995 +/- 648)/mm(2) and the rate of endothelial cell loss was (20.6 +/- 14.1)%; In group II, the corneal endothelial cell density before and after operation was (2459 +/- 681)/mm(2) and (2238 +/- 817)/mm(2) respectively. The rate endothelial cell loss was higher in group I compared with group II (P = 0.023). Postoperative complication include transient secondary glaucoma caused by block of pupil in 4 eyes and remain of viscoelastic substance in 3 eyes, hypotension in 5 eyes, persistent glaucoma in 2 eyes, hyphema in 2 eyes, IOLs slightly dislocation and shift in 3 eyes, pupil deformation in 1 eye, retina detachment in 2 eyes, and corneal decompensation in 2 eyes. Flexible open-loop ACIOL is relatively safe and effective in selected cataract surgery. Postoperative complication could be reduced if operative indication and surgical technique were emphasized.

Corneal Endothelial Cells' Protection against Thermal Injury: Influence of Ophthalmic Viscoelastic Substances in Experimental Study on Rabbits

To quantify the maximal level of temperature and the time the maximal temperature is achieved and correlate the temperature parameters to the mean rate of endothelial cell loss after standardized ultrasound delivery assisted with four viscoelastic substances or different temperature of balanced salt solution (BSS). Thirty rabbits (60 eyes) were divided into six groups in which different viscoelastic substances or different temperature of BSS were used: Group 1, Viscoat; 2, Provisc; 3, soft shell technique; 4, Celoftal; 5, BSS 22 degrees C; and 6, BSS 4 degrees C. The same parameters of ultrasound energy were delivered by standard phaco tip introduced into pupillary plane. Thermocamera was employed for measurements of temperature parameters. Endothelium cell count was measured before surgery and 1 month postoperatively. Maximal level of temperature was measured as follows: Group 5, 27.85 +/- 0.52 degrees C; Group 2, 27.75 +/- 0.54 degrees C; Group 3, 27.74 +/- 0.46 degrees C; Group 4, 27.25 +/- 0.60 degrees C; Group 6, 26.81 +/- 0.34 degrees C; Group 1, 26.52 +/- 0.48 degrees C (p<0.05). The time the maximal temperature is achieved was statistically shorter in Groups 5 and 6: 4 seconds, 5 seconds, respectively, p<0.0001, as compared with Group 2 (30 seconds), Group 3 (40 seconds), Group 1 (45 seconds), and Group 4 (50 seconds). The mean rate of endothelial cell loss was calculated as follows: Group 1, 4.35%+/-2.55%; Group 2, 8.43%+/-5.2%; Group 3, 6.25%+/-4.20%; Group 4, 6.53%+/-4.65%; Group 5, 14.3%+/-3.85%; and Group 6, 8.78%+/-4.45%. Viscoelastic substances offer different levels of endothelial cell protection against temperature increase during phacoemulsification. The mean rate of endothelial cell loss correlates with the time the maximal temperature is achieved rather than with the value of maximal level of temperature. This implicates that surgical strategy should consider the choice of the most effective viscoelastic substances, particularly in difficult cases, e.g., hard nucleus, shallow anterior chamber, primary endothelial abnormality.

Correction of Myopia of 7 to 24 Diopters With the Artisan Phakic Intraocular Lens: Two-year Follow-up

To evaluate the safety and efficacy of the iris claw phakic intraocular lens (Artisan; Ophtec BV, Groningen, The Netherlands) in patients with high myopia. Between May 1999 and July 2001, 93 Artisan phakic intraocular lenses (IOLs) were implanted in 60 patients affected by high myopia. All patients underwent 24-month follow-up. The power of the lenses ranged from -7.5 to -22.0 diopters (D). Patients were divided into two groups: group 1 (68 eyes), myopia -6.75 to -15.50 D (SE), and group 2 (25 eyes), myopia -16.0 to -23.0 D (SE). Pre- and postoperative patient evaluation included manifest and cycloplegic refractions, uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BSCVA), endothelial cell count, intraocular pressure, complication rate, safety, and efficacy. At 4 months, 83.8% (57/68) (group 1, myopia -6.75 to -15.50 D) and 68% (17/25) (group 2, myopia -16.0 to -23.0 D) of eyes achieved UCVA of > or =20/40. The BSCVA remained the same or improved in 100% of eyes. After 4 months, 69.1% (47/68) of eyes in group 1 and 52% (13/25) of eyes in group 2 were within +/-1.00 D of the desired refraction; the mean refraction was stable between 4 and 24 months. Of the intraoperative complications, 69.2% were observed in the first 25 lenses implanted; postoperative complications included iris atrophy in 11.8% (11/93), lens decentration in 5.4% (5/93), and night glare in 6.4% (6/93) of eyes. No IOLs were removed. Mean endothelial cell loss was 2.8% at 4 months, 3.9% at 12 months, and 5.4% at 24 months. Our results regarding implantation of the Artisan phakic IOL confirm that these lenses are safe and effective for the correction of high myopia, with a stable refractive outcome but with a higher than normal rate of endothelial cell loss during 2-year follow-up.

Corneal endothelium and postoperative outcomes 15 years after penetrating keratoplasty

To determine changes in the central endothelium and thickness of grafted corneas and the cumulative probability of developing glaucoma, of graft rejection, and of graft failure 15 years after penetrating keratoplasty. Longitudinal cohort study of 500 consecutive penetrating keratoplasties by one surgeon. Regrafted eyes, fellow eyes of bilateral cases, and patients not granting research authorization were excluded, leaving 388 grafts for analysis. At intervals after surgery, we photographed the endothelium and measured corneal thickness using specular microscopy. The presence of glaucoma, graft rejection, and graft failure were recorded. The 67 patients examined at 15 years represented 30% of the available clear grafts. Endothelial cell loss from preoperative donor levels was 71 +/- 12% (mean +/- standard deviation, n = 67), endothelial cell density was 872 +/- 348 cells/mm(2), and corneal thickness was 0.59 +/- 0.06 mm. Endothelial cell density was unchanged between 10 and 15 years, whereas corneal thickness increased (P = .001, n = 55). The mean annual rate of endothelial cell loss from 10 to 15 years after surgery was 0.2 +/- 5.7% (n = 54). The cumulative probability of developing glaucoma, graft rejection, or graft failure was 20%, 23%, and 28%, respectively, and 6 of the 8 graft failures after 10 years resulted from late endothelial failure. From 10 to 15 years after penetrating keratoplasty, the annual rate of endothelial cell loss was similar to that of normal corneas, corneal thickness increased, and late endothelial failure was the major cause of graft failure.

Efficacy of the soft-shell technique using Viscoat and Hyal-2000

Purpose: To evaluate whether the soft-shell technique using Viscoat® (sodium hyaluronate 3%–chondroitin sulfate 4%) and Hyal-2000® (sodium hyaluronate 1%) reduces corneal endothelial cell damage during cataract surgery. Setting: Department of Ophthalmology, Kangnam St. Mary's Hospital, Seoul, Korea. Methods: The nuclear opacity in 252 eyes of 230 cataract patients was classified as grade 1, 2, 3, or ≥4 using the Lens Opacities Classification System III. In each classification, the patients were divided into 4 groups before phacoemulsification based on the type of ophthalmic viscosurgical device (OVD) used during surgery: Viscoat and Hyal-2000 (soft-shell technique), Viscoat alone, Hyal-2000 alone, or Provisc® (sodium hyaluronate 1%) alone. All patients were operated on using the same technique except for the OVD. The visual acuity, corneal endothelial cell density, corneal thickness, and intraocular pressure (IOP) were evaluated postoperatively. Results: The rate of endothelial cell loss 2 months after surgery in eyes with a nuclear opacity grade of ≥4 was significantly different between the 4 OVD groups. The rate in eyes with a nuclear opacity grade of ≤3 was not significantly different between the groups. There were no statistically significant differences between the 4 groups in visual acuity, corneal thickness, or IOP throughout the follow-up period. Conclusion: The soft-shell technique using Viscoat and Hyal-2000 protected corneal endothelial cells during cataract surgery in patients with a nuclear opacity grade of ≥4.