Severe Endothelial Cell Loss Research Articles

Spontaneous lens luxation into anterior chamber: why is it important to intervene immediately?

A 70-year-old woman, with a history of cataract surgery 2 years ago, presented to the ophthalmology clinic with 3 months of decreased vision, pain and redness in his right eye. Visual acuity was limited to hand motion and intraocular pressure was normal. Slit lamp examination showed a lens luxation into the lower part of the anterior chamber, diffuse corneal edema and corneal neovascularization. Fundus examination was unremarkable. Specular microscopy showed severe endothelial cell loss in the right eye and moderate in the left eye, testifying preexistent corneal endothelial dystrophy. Anterior segment optical coherence tomography showed increased thickness in the affected eye. Postural measures have been recommended, and the lens implant was extracted rapidly. Endothelial keratoplasty was performed later. Corneal edema may occur due to endothelial pump failure because of the direct contact between the corneal endothelium and the lens. Others causes have been incriminated such as chemical injury, infection, inflammation, corneal dystrophy. The management of corneal edema depends upon the underlying cause and visual potential, starting from the medical management to penetrating keratoplasty. This case highlighted the importance of early management in case of lens luxation into the anterior chamber (AC) in order to minimize the risk of endothelial cell loss.

Five Years Pathological Evaluation of Corneal Regrafts: A Study from Southern Iran.

Purpose Corneal regrafts sometimes needed to restore the transparency after graft failure. The aim of the study is five years epidemiologic and histopathological evaluation of corneal regrafts. Methods In this cross-sectional study, all corneal regrafts during 5 years (2012–2016) were assessed in the Khalili Ophthalmology Center at Shiraz city. Demographic data including age, area of residence, primary disease, type of graft, cause of regraft, interval between primary and subsequent grafts (IPSG), associated eye diseases or surgeries, and systemic diseases were recorded. Also, microscopic findings of corneas were reviewed. Results Among a total of 1190 corneal grafts, 76 of them (6.38%) were regrafts. The most common type of grafting was penetrating keratoplasty (PK). The shortest IPSG was observed in fungal keratitis. Main causes of graft failure were endothelial dysfunction, infection, immunologic rejection, technical problems, and recurrence of primary disease, respectively. The most common histopathological finding in failed grafts was severe endothelial cell loss (89.8%). Also, more than half and one-third of cases had Descemet membrane changes and stromal ingrowth, respectively. Conclusion Endothelial cell loss was the major cause of failure in our study. Also, recurrence rate in infective cases, especially fungal keratitis, was very high. Considerable presence of histopathological changes such as doubling of Descemet membrane and retrocorneal fibrous ingrowth need further investigations. Perhaps, modification in techniques of corneal grafting and assessment of donor tissue and recipient bed along with any need for longer medical treatment are the basis for future studies in order to increase graft survival.

Explantation of phakic intraocular lenses: causes and outcomes.

To describe reasons for explantation of anterior and posterior chamber phakic intraocular lenses (pIOLs), as well as outcomes of the surgery. The medical files of patients who underwent pIOL explantation due to complications were reviewed. All patients were divided into three groups based on the type of explanted pIOL: anterior chamber angle-supported (AS pIOL), anterior chamber iris-fixated (IF pIOL), and posterior chamber (PC pIOL). Sixty-two eyes of 41 patients were evaluated. There were 26 (41.9%), 16 (25.8%), and 20 (32.2%) eyes in the AS pIOL, IF pIOL, and PC pIOL groups, respectively. The mean interval between the implantation and removal of the pIOL (i.e., survival time) was 13.6 ± 8.1years (range 0.01-21.22years). The mean follow-up after the explantation was 22.5 ± 4.0months (range 11.3-28.7months). The main causes of explantation were cataract in the PC pIOL group (60%) and chronic endothelial cell loss in the AS pIOL group (53.8%) and IF pIOL group (56.2%). Overall, the procedure most often combined with pIOL explantation was phacoemulsification and implantation of a posterior chamber IOL (40.3%), followed by keratoplasty (9.6%). Intraoperative complications were significantly more common in the AS pIOL group than the other groups (p < 0.001). Explantation of anterior chamber pIOLs due to severe endothelial cell loss and the proportion of keratoplasty was more common in patients with a relatively long survival time. Therefore, patients with pIOL implantation should be monitored regularly after surgery.

Consecutive drilling combined with phaco chop for full thickness segmentation of very hard nucleus in coaxial microincisional cataract surgery

BackgroundThe complete disassembly of nuclear is the most challenging step in hard cataract surgery through microincision. The classic phaco chop technique often does not succeed, resulting in incomplete nuclear segmentation. The authors describe a technique to improve the efficacy and safety of the initial chopping.MethodsThe consecutive drilling combined with phaco chop technique was devised for very hard cataract through a microincision of 1.8–2.2 mm. 3–4 holes are consecutively drilled into the endonucleus with the phaco tip bevel down, at an angle of approximate 60 degrees and depth of approximately two-thirds of the lens thickness. The initial drilling approaches the capsulorhexis edge and the last drilling approaches the lens geometric center. The nucleus is deeply impaled with the last drilling and firmly engaged with high vacuum, and then chopped with chopper centripetally from the lens equator. The chopper and phaco tip are spread apart laterally after they approach at the center of the nucleus, to create a complete fracture across the entire nucleus. This technique has been adopted in 80 eyes of 65 patients with cataract harder than nuclear opalescence 5 on the Lens Opacities Classification System III scale or mature white cataract with a hard nucleus in the past 12 months.ResultsIn all cases, full thickness segmentation of the hard nuclear including the posterior plate was achieved with this consecutive drilling combined with phaco chop technique. Phacoemulsification and intracapsular implantation of intraocular lens was safely performed in each case. No intraoperative complication such as iris injury, anterior capsule tears, zonulysis or posterior capsule rupture with vitreous loss occurred during surgery. No postoperative complication such as fibrin formation, synechias, severe endothelial cell loss, or endophthalmitis was observed in any case at 6 months postoperatively.ConclusionsThe technique is an efficient, safe, simple, and swift procedure for full-thickness nuclear segmentation, delivering advantage of microincisional phacoemulsifcation for hard cataract with few ocular complications.

Long-term (≥10 years) results of corneal endothelial cell loss after cataract surgery

To investigate the extent of long-term corneal endothelial loss after uneventful cataract surgery and the factors associated with decreases in corneal endothelial cell density (ECD). Retrospective case series. Patients who had undergone uncomplicated cataract surgery. This study comprised 81 eyes of 48 patients who had undergone cataract surgery >10 years previously by a single surgeon with the same intraocular lens and visited the outpatient clinic between January 2014 and February 2017. Long-term (≥10 years) changes in visual outcome and ECD after uncomplicated cataract surgery were evaluated. To analyze factors correlated with endothelial cell loss, preoperative biometric variables, including cataract grade, anterior chamber depth, axial length, and postoperative corneal edema, were evaluated. The mean ± SD preoperative and long-term postoperative ECD was 2793 ± 351.09 and 2148 ± 478.38 cells/mm2, respectively. The mean follow-up period was 11.08 ± 1.06 years and 10-year ECD loss rate was 20.62 ± 13.63%. Preoperative nuclear firmness was most statistically correlated with 10-year ECD loss (β-coefficient 0.394 [95% CI 3.402-9.448]; p < 0.001). The degree of postoperative corneal edema was also a significant predictive factor of 10-year ECD loss after cataract surgery (β-coefficient 0.378 [95% CI 2.854-8.358]; p = 0.002). Preoperative nuclear firmness and postoperative corneal edema were predictors of long-term (≥10 years) endothelial cell loss and severe endothelial cell loss after cataract surgery. It is important to remember that eyes with increased nuclear firmness have a significantly higher risk of long-term enhanced ECL.

Corneal endothelial cell loss after Baerveldt glaucoma drainage device implantation in the anterior chamber.

PurposeTo investigate central and peripheral corneal endothelial cell density (ECD) in relation to Baerveldt (BV) glaucoma drainage device (GDD) tube corneal (TC) distance.MethodsProspective study of all patients scheduled for glaucoma tube surgery with 36 months follow‐up. A BV GDD was inserted into the anterior chamber (AC). Anterior segment optical coherence tomography (AS‐OCT) scans were made to determine the TC distance. Central and peripheral ECD was measured, preoperatively and at 3, 6, 12, 24 and 36 months postoperatively.ResultsFifty‐three eyes were included [primary open‐angle glaucoma, (n = 13); secondary glaucoma, (n = 30); and primary angle‐closure glaucoma, (n = 10)]. Central ECD significantly decreased during follow‐up, with a mean decrease of 4.54% per year (p < 0.001), and 6.57% in the peripheral quadrant closest to the BV GDD tube (PQC, p < 0.001). In the PQC, a yearly decrease of 1.57% was shown after transiridial tube placement versus 7.43% after placement ‘free’ into the AC (p = 0.006). Endothelial cell (EC) loss was related to TC distance (mean 1.69 mm), with a central loss of 6.20% and 7.25% in the PQC per year with shorter TC distances, versus a central loss of 4.11% and 5.77% in the PQC per year with longer TC distances (outside mean ± 2SD, p < 0.001). A difference in EC loss by glaucoma subtype was not identified.ConclusionThe TC distance is of significant influence on corneal ECD, a shorter TC distance causing more severe EC loss, especially in the PQC. Transiridial placement of the BV GDD tube seems safer than placement ‘free’ into the AC.

Long-Term Observation of Triplex Surgery for Cataract after Phakic 6H Implantation for Super High Myopia

Purpose. To analyze the safety, effectiveness, and stability of triplex surgery for phakic 6H anterior chamber phakic intraocular lens explantation and phacoemulsification with in-the-bag IOL implantation for super high myopia in long-term observations. Methods. This retrospective case series evaluated 16 eyes of 10 patients who underwent triplex surgery. Best corrected visual acuity (BCVA), endothelial cell density (ECD), and associated adverse events were evaluated. Results. The mean follow-up time after the triplex surgery was 46 ± 14 months. The mean logMAR BCVA was significantly improved after triplex surgery (P = 0.047). One eye developed endophthalmitis five days postoperatively and underwent pars plana vitrectomy (PPV). Five eyes with preoperative severe endothelial cell loss developed corneal decompensation and underwent keratoplasty at a mean time of 9.4 ± 2.6 months after the triplex surgery. One eye had graft failure and underwent a second keratoplasty. The eye developed rhegmatogenous retinal detachment and underwent PPV with silicone oil 18 months later. ECD before the triplex surgery was not significantly different compared with that at last follow-up (P = 0.495) apart from these five eyes. Three eyes (18.8%) developed posterior capsule opacification. Conclusions. Triplex surgery was safe and effective for phakic 6H related complicated cataracts. Early extraction before severe ECD loss is recommended.

Clinical Outcomes in Cytomegalovirus-Positive Posner-Schlossman Syndrome Patients Treated With Topical Ganciclovir Therapy

To evaluate the clinical characteristics and therapeutic outcomes of cytomegalovirus (CMV)-positive Posner-Schlossman syndrome patients undergoing topical ganciclovir treatment. Retrospective, comparative, and interventional case series. One eye of each of 126 consecutive Posner-Schlossman syndrome patients was investigated using aqueous polymerase chain reaction (PCR) between January 2006 and June 2013. The initial presentations and follow-up data of the CMV-positive patients (68 eyes) and CMV-negative patients (58 eyes) were compared. Severe endothelial cell loss (P < .001) and a higher number of eyes requiring glaucoma filtering surgery (P = .017) were observed in CMV-positive Posner-Schlossman syndrome patients. All CMV-infected eyes treated with continual topical 2% ganciclovir exhibited an undetectable CMV level at the following taps. During follow-up, the average number of antiglaucomatous agents decreased, and a similar frequency of intraocular pressure (IOP) spikes was observed in both groups (P = .358). Patients with CMV-positive eyes with a disease duration over 5 years were likely to require glaucoma surgery (P = .024, log-rank test). All patients receiving surgery exhibited CMV-negative PCR during the IOP attack, but experienced severe peripheral anterior synechiae and pigment clogging. Both groups exhibited a similar endothelial cell decrease (P = .243) and probability of progressive endothelial cell loss (P = .219, log-rank test). Ganciclovir treatment was effective for clearing the viral load, assisting the IOP control, and preserving the corneal endothelium of CMV-positive Posner-Schlossman syndrome patients. Early diagnosis and proper treatment could decrease the risk of advanced glaucoma and avoid glaucoma surgery in long-lasting cases.

Clinical Evaluation of a New Donor Graft Inserter for Descemet’s Stripping Automated Endothelial Keratoplasty

To present clinical outcomes of Descemet's stripping automated endothelial keratoplasty (DSAEK) using a newly developed donor graft inserter, the Tan EndoGlide (AngioTech, Reading, PA/Network Medical Products, North Yorkshire, UK). Six eyes of six patients with bullous keratopathy were treated with DSAEK using the Tan EndoGlide. Intraoperative and postoperative complications, postoperative donor endothelial cell densities (ECDs), and best-corrected visual acuity were recorded. Five cases had no difficulties during donor graft loading into the Tan EndoGlide; however, the donor graft was folded inside-out into the Tan EndoGlide in one case, resulting in severe endothelial cell loss. All patients achieved a visual acuity of 20/63 or better at 12 months, with four patients reaching better than 20/32. Excluding the case with the graft folded inside-out, postoperative ECDs were 2,041 cells/mm(2) (mean loss: 22.9%) at 6 months and 1,973 cells/mm(2) (mean loss: 24.6%) at 12 months. In this small preliminary series, the clinical outcome with the Tan EndoGlide was comparable to or better than that achieved with the conventional technique. Additional studies using a larger number of patients are required to fully evaluate the usefulness and potential advantages of this new donor graft inserter.

Simultaneous bilensectomy and endothelial keratoplasty for angle-supported phakic intraocular lens-induced corneal decompensation

A 40-year-old lady presented with severe endothelial cell loss in both eyes 14 years after angle-supported phakic intraocular lens (AS PIOL) implantation. The left eye had severe corneal edema with bullous keratopathy. The right eye had markedly reduced endothelial cell count (655 cells/mm2) although the cornea was clear. She underwent simultaneous bilensectomy (AS PIOL explantation and phacoemulsification) and Descemet's stripping and endothelial keratoplasty (DSEK) in the left eye. Explanted AS PIOL was identified as ZSAL-4 (Morcher, Stuttgart, Germany) model. Corneal edema cleared completely in 2 months with a best corrected visual acuity (-2.25 D sph) of 20/60. No intervention was done in the right eye. The present case illustrates that AS PIOL-induced endothelial decompensation can be effectively managed by simultaneous bilensectomy and endothelial keratoplasty.

Serious complications of cosmetic NewColorIris implantation

This case report describes serious postoperative complications and markedly elevated intraocular pressure (IOP) associated with the NewColorIris cosmetic implant. We report an interventional case series of two patients who suffered multiple complications after NewColorIris implantation carried out in Panama. Assessment included visual acuity, photography, endothelial cell count and anterior segment optical coherence tomography (OCT) when possible. Both patients presented with endothelial cell loss, uveitis, pigment dispersion and elevated IOP. Anterior segment OCT demonstrated irregularities in the position and configuration of the implants within the anterior chamber with resultant areas of implant-iris and implant-endothelial contact. One patient had acute postoperative hyphaema that resolved with anterior chamber tissue plasminogen activator injection. Both patients required explantation OU, one eye has required trabeculectomy, and one eye with bullous keratopathy is being evaluated for Descemet's stripping endothelial keratoplasty. Implantation of the NewColorIris cosmetic implant can lead to serious complications including hyphaema, uncontrolled IOP, severe endothelial cell loss, bullous keratopathy and anterior uveitis. Explantation may lead to improvement, but permanent damage to the trabecular meshwork and corneal endothelium persists.

Severe endothelial cell loss following uneventful angle-supported phakic intraocular lens implantation for high myopia

Endothelial decompensation is a serious complication of phakic intraocular lens (pIOL) implantation and is a major concern during the postoperative period. We report 3 eyes in which the same foldable angle-supported pIOL was implanted to correct high myopia. Rapid and severe postoperative endothelial cell loss occurred in all 3 eyes. An over-sized pIOL that induced excessive vaulting into the anterior chamber was the main risk factor. In 2 eyes, the pIOL was explanted uneventfully; 1 eye required Descemet's stripping automated endothelial keratoplasty because of total endothelial decompensation. These cases illustrate the importance of accurate sizing of foldable angle-supported anterior chamber pIOLs to avoid excessive vaulting. They also highlight the importance of regular follow-up and preventive pIOL explantation as soon as significant endothelial cell loss is detected.

Angle-Supported Anterior Chamber Phakic Intraocular Lens Explantation: Causes and Outcome

To investigate the reasons for explantation of angle-supported phakic intraocular lenses (IOLs) as well as the outcome and safety of the explantation procedure. Consecutive retrospective series. One hundred eyes of 66 patients who underwent phakic angle-supported IOL explantation. Surgical explantation of anterior chamber angle-supported phakic IOLs. Visual acuity, refraction, and endothelial cell density. The main causes of explantation were cataract development (64 cases [64%]), progressive endothelial cell loss (24 cases [24%]), and pupil ovalization (10 cases [10%]). According to the reason for phakic IOL explantation and the condition of the eye at time of explantation, 92 cases underwent bilensectomy (phakic IOL explantation followed by phacoemulsification of the crystalline lens), 2 cases underwent phakic IOL exchange, 4 cases underwent concomitant phakic IOL explantation and penetrating keratoplasty, and 2 cases underwent simple explantation of a phakic IOL. The mean time between phakic anterior chamber IOL implantation and explantation due to cataract was 10.04+/-3.66 years (range, 2-14). The mean time between implantation and secondary intervention due to progressive endothelial cell loss was 8.97+/-2.21 years (range, 2-14), and most of these cases were related to a specific model of angle-supported phakic IOL. Nuclear cataract was the most frequent reason for angle-supported phakic IOL explantation. Bilensectomy was effective and maintained the refractive benefits obtained with phakic IOL implantation. Few cases developed severe endothelial cell loss, most of them related to certain types of phakic IOLs.

Penetrating keratoplasty for treatment of fungal keratitis with corneal perforation

To evaluate the outcome of penetrating keratoplasty (PKP) for the treatment of fungal keratitis with corneal perforation. 40 patients (40 eyes) with corneal perforation secondary to fungal keratitis underwent PKP at Qingdao Eye Hospital from 1994 to 2003. The follow-up ranged from 6-24 months. The postoperative visual acuity and complications were documented. 39 (97.5%) patients preserved the eyeballs. The visual acuity improved in 38 (95.0%) eyes. Fungal infection recurred in 4 eyes, 3 of which were controlled with antifungal medication and 1 was enucleated because of the uncontrolled endophthalmitis. Graft rejection was observed in 15 (37.5%) eyes, 12 of which were cured with medication and 3 received secondary PKP. 3 (7.5%) eyes had graft ulceration, 2 of which were cured and the other one was regrafted because of severe endothelial cell loss. 5 (12.5%) eyes had secondary glaucoma, and the intraocular pressure was controlled medically and surgically. Complicated cataract occurred in 5 (12.5%) eyes, 3 of which underwent cataract extraction. Most complications were controlled successfully. At last follow-up, 36 (90.0%) grafts were clear. PKP is an effective approach for preservation of eyeballs and restoration of visual function in patients eyes with fungal keratitis and corneal perforation.

Long-term complications of bilateral posterior chamber phakic intraocular lens implantation

A 34-year-old woman had posterior chamber phakic intraocular lens (PCP IOL) implantation to correct high myopia in both eyes. Five years postoperatively, the patient presented with a decrease in visual acuity from central anterior subcapsular cataract formation in both eyes and IOL dislocation in the left eye. In vivo confocal microscopy of the cornea showed markedly decreased endothelial cell density in both eyes and the presence of bright endothelial microdeposits possibly related to pigmentary dispersion. Gonioscopy showed angle pigmentary deposits with no intraocular pressure increase. The patient was successfully treated by removing the PCP IOLs and performing phacoemulsification with in-the-bag IOL implantation in both eyes. This led to a recovery of visual acuity. This case report presents the rare occurrence and surgical management of cataract formation, IOL dislocation, and severe endothelial cell loss as a late complication of PCP IOL implantation.

The Effect of Glaucoma Filtering Surgery on Corneal Endothelial Cell Density

Corneal endothelial cell counts were obtained preoperatively and 3 months postoperatively in 46 eyes undergoing glaucoma filtering surgery. Average central endothelial cell loss in eyes without postoperative iridocorneal touch was 1.6%. In eyes with iridocorneal touch (Spaeth's grades 1 and 2), the average cell counts decreased by 7.1% and 9.3%, respectively. The average loss for combined grades 1 and 2 (8.1%) approached statistical significance (P +/- .06). The average loss in two patients with corneolenticular touch (Spaeth's grade 3) was greater than 50%. These findings suggest that early postoperative iridocorneal touch is unlikely to lead to corneal compromise in most eyes, but that corneolenticular touch can result in severe endothelial cell loss.