Surgical Options for the Refractive Correction of Keratoconus: Myth or Reality

Keratoconus provides a decrease of quality of life to the patients who suffer from it. The treatment used as well as the method to correct the refractive error of these patients may influence on the impact of the disease on their quality of life. The purpose of this review is to describe the evidence about the conservative surgical treatment for keratoconus aiming to therapeutic and refractive effect. The visual rehabilitation for keratoconic corneas requires addressing three concerns: halting the ectatic process, improving corneal shape, and minimizing the residual refractive error. Cross-linking can halt the disease progression, intrastromal corneal ring segments can improve the corneal shape and hence the visual quality and reduce the refractive error, PRK can correct mild-moderate refractive error, and intraocular lenses can correct from low to high refractive error associated with keratoconus. Any of these surgical options can be performed alone or combined with the other techniques depending on what the case requires. Although it could be considered that the surgical option for the refracto-therapeutic treatment of the keratoconus is a reality, controlled, randomized studies with larger cohorts and longer follow-up periods are needed to determine which refractive procedure and/or sequence are most suitable for each case

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Paracentesis as valve re-bubbling technique for Descemet’s membrane endothelial keratoplasty (DMEK) graft detachment

Introduction We present a variation in the slit-lamp microscope re-bubbling technique for DMEK detachment in which a paracentesis is used as a self-sealing valve. Methods Of twenty-eight consecutive DMEK cases, five (18%) required re-bubbling. A 20-gauge side port blade was used to make a paracentesis in the inferior temporal quadrant. A 30-gauge cannula mounted on a 3 ml syringe was employed to inject air using the paracentesis as a valve allowing better control over intraocular pressure and percentage anterior chamber air fill. Results Graft re-attachment was achieved in all cases. One case required two re-bubbling procedures. There were no cases of pupil block glaucoma or other complications. Conclusion Slit-lamp re-bubbling is a practical and safe alternative to taking patients back to the operating room. Using a new paracentesis for valve action control over air injection with a blunt cannula adds better control and may help to reduce complications

Deep Anterior Lamellar Keratoplasty for Keratoconus: Multisurgeon Results

PURPOSE: To examine clinical outcomes in deep anterior lamellar keratoplasty (DALK) for keratoconus using contemporary techniques in a multisurgeon public healthcare setting.DESIGN: Consecutive, retrospective case series.METHODS: SETTING: Moorfields Eye Hospital, London, United Kingdom. STUDY POPULATION: Consecutive cases of keratoconus treated with non laser assisted DALK from September 1, 2012, to September 31, 2016. OBSERVATION PROCEDURE: Data on preoperative status, operative details, intraoperative and postoperative complications, secondary interventions, and visual outcomes were archived for analysis. MAIN OUTCOME MEASURES: Graft failure rate and percentage of patients with corrected distance visual acuity (CDVA) >= 20/40 within 1 year of surgery and at final review after suture removal.RESULTS: Three hundred fifty-seven eyes of 338 patients undergoing DALK (91.3% big -bubble technique attempted) were analyzed. A total of 4.2% (95% confidence interval [CI] 2.4%-6.8%) of corneal transplants had failed within the follow-up period (21.8 +/- 11.4 months), and 75.9% of eyes had CDVA >= 20/40 within 1 year of surgery, rising to 81% after suture removal. Forty-two primary surgeons (31 trainees) participated. Intraoperative perforation of Descemet membrane occurred in 45.4% of eyes. A total of 24.1% were converted to penetrating keratoplasty (PK) intraoperatively. Conversion to PK increased the risk of transplant rejection (P=.026; odds ratio [OR] 1.94; 95% CI 1.1-3.5) and secondary glaucoma (P=.016; OR 4.0; 95% CI 1.3-12.4). Transplant rejection increased the risk of graft failure both overall (P=.017; OR= 3.9; 95% CI 1.4-11.0) and when cases converted to PK were excluded (P=.028; OR= 3.35; 95% CI 1.1-9.9).CONCLUSION: DALK for keratoconus achieves early results similar to those published for PK in a multisurgeon setting. Conservative management of intraoperative Descemet membrane perforation, where possible, may be safer than conversion to PK. ((C) 2019 Elsevier Inc. All rights reserved.

Surgical options for the refractive correction of keratoconus: Myth or reality

Keratoconus provides a decrease of quality of life to the patients who suffer from it. The treatment used as well as the method to correct the refractive error of these patients may influence on the impact of the disease on their quality of life. The purpose of this review is to describe the evidence about the conservative surgical treatment for keratoconus aiming to therapeutic and refractive effect. The visual rehabilitation for keratoconic corneas requires addressing three concerns: halting the ectatic process, improving corneal shape, and minimizing the residual refractive error. Cross-linking can halt the disease progression, intrastromal corneal ring segments can improve the corneal shape and hence the visual quality and reduce the refractive error, PRK can correct mild-moderate refractive error, and intraocular lenses can correct from low to high refractive error associated with keratoconus. Any of these surgical options can be performed alone or combined with the other techniques depending on what the case requires. Although it could be considered that the surgical option for the refracto-therapeutic treatment of the keratoconus is a reality, controlled, randomized studies with larger cohorts and longer follow-up periods are needed to determine which refractive procedure and/or sequence are most suitable for each case

Femtosecond Laser–Assisted Deep Anterior Lamellar Keratoplasty for Keratoconus: Multi-surgeon Results

Purpose: To compare the clinical outcomes in femtosecond laser–assisted deep anterior lamellar keratoplasty (F-DALK) to manual non-laser deep anterior lamellar keratoplasty (M-DALK) for keratoconus in a multi-surgeon public healthcare setting. Design: Single-center, comparative, retrospective interventional case series. Methods: POPULATION: Consecutive cases of keratoconus treated with big-bubble F-DALK from August 1, 2015, to September 1, 2018 and big-bubble M-DALK from September 1, 2012, to September 30, 2016. SETTING: Moorfields Eye Hospital, London. OBSERVATIONS: Data on preoperative status, operative details, intraoperative and postoperative complications, secondary interventions, and visual outcomes were archived on a customized spreadsheet for analysis. MAIN OUTCOME MEASURES: Rate of intraoperative perforation and conversion to penetrating keratoplasty (PK) and the percentage of patients, post removal of sutures (ROS), with corrected distance visual acuity (CDVA) ≥20/40. Results: We analyzed 58 eyes of 55 patients who underwent F-DALK and 326 eyes of 309 patients who underwent M-DALK. Intraoperative perforation of Descemet membrane occurred in 15 of 58 (25.9%) F-DALK cases compared to 148 of 326 (45.4%) M-DALK cases (P = .006). Intraoperative conversion to PK was carried out in 2 of 58 (3.4%) F-DALK cases compared to 80 of 326 (24.5%) M-DALK cases (P = .001). Post ROS, 86.5% of F-DALK eyes had a CDVA of ≥20/40 (15 ± 7.3 months after surgery) compared to 83.7% of M-DALK eyes (24.9 ± 10.6 months) (P =. 825). Conclusion: Laser automation of some steps in DALK for keratoconus may reduce the rate of intraoperative Descemet perforation and the conversion to PK in a multi-surgeon setting

Eye bank versus surgeon prepared DMEK tissues: influence on adhesion and re-bubbling rate

Aim: To investigate the difference in adhesion and rebubbling rate between eye bank and surgeon prepared Descemet membrane endothelial keratoplasty (DMEK) tissues. Methods: Laboratory and clinical retrospective comparative interventional case series. Research corneal tissues were obtained for laboratory investigation. The clinical study involved patients with endothelial dysfunction who underwent DMEK surgery and tamponade with air. Tissues were stripped using a standard DMEK stripping technique (SCUBA) and shipped as prestripped or loaded in a 2.2 intra-ocular lens cartridge with endothelium facing inwards (preloaded) before transporting from the eye bank to the surgeon. For surgeon prepared tissues, all the grafts were stripped in the theatre and transplanted or stripped in the laboratory and tested immediately. Adhesion force and elastic modulus were measured in the centre and mid-periphery in a laboratory ex vivo investigation using atomic force microscopy, while rebubbling rates were recorded in the clinical study. Results: There was no difference in endothelial cell viability between surgeon or eye bank prepared tissue. Surgeon-stripped DMEK grafts in the laboratory investigation showed significantly higher elastic modulus and adhesion force compared to prestripped and preloaded tissues (p<0.0001). In the clinical data, rebubbling rates of 48%, 40% and 15% were observed in preloaded, prestripped and surgeon-stripped DMEK grafts, respectively. Rebubbling rates were significantly associated with combined cataract surgery (p=0.009) and with time from harvesting the graft to the surgery (p=0.02). Conclusions: Decreased adhesion forces and elastic modulus in eye bank prepared tissues may contribute to increased rebubbling rates

Recommendation for Presbyopia-Correcting Intraocular Lenses: A Delphi Consensus Statement by the ESASO Study Group

Purpose: To establish consensus among experts in lens and refractive surgery to guide general ophthalmologists on issues related to presbyopia-correcting intraocular lenses (IOLs). Design: A modified Delphi method to reach a consensus among experts. Methods: A steering committee formulated 105 relevant items grouped into four sections (preoperative considerations, IOL selection, intraoperative considerations, and postoperative considerations). The consensus was defined as ≥ 70% of experts agreeing with the evaluation of a statement. Results: Ten experts participated and completed all rounds of questionnaires (100% response rate). Of 68 items considered in the preoperative considerations, consensus was achieved in 48 (70.6%). There was a lack of consensus over IOL selection, the experts only agreed on the importance of the patient's habits for the optical IOL design selection. Of the 14 considerations related to intraoperative issues, the experts reached a consensus on 10 (71.4%). The postoperative considerations section reached the highest consensus in 10 items of 13 (76.9%). Conclusions: Key recommendations for a diffractive multifocal IOL were a potential postoperative visual acuity > 0.5, a keratometry between 40-45 diopters, a pupil >2.8 mm under photopic conditions and <6.0 mm under scotopic conditions, a root mean square of higher order corneal aberrations <0.5 µm for 6-mm pupil size, while monofocal or non-diffractive IOLs should be considered for patients with coexisting eye disorders. A lack of agreement was found in the issues related to the IOL selection

Antimicrobial management of Tropheryma whipplei endocarditis: the Spanish Collaboration on Endocarditis (GAMES) experience

OBJECTIVES: Tropheryma whipplei has been detected in 3.5% of the blood culture-negative cases of endocarditis in Spain. Experience in the management of T. whipplei endocarditis is limited. Here we report the long-term outcome of the treatment of previously reported patients who were diagnosed with infective endocarditis (IE) caused by T. whipplei from the Spanish Collaboration on Endocarditis-Grupo de Apoyo al Manejo de la Endocarditis Infecciosa en Espana (GAMES) and discuss potential options for antimicrobial therapy for IE caused by T. whipplei. PATIENTS AND METHODS: Seventeen patients with T. whipplei endocarditis were recruited between 2008 and 2014 in 25 Spanish hospitals. Patients were classified according to the therapeutic regimen: ceftriaxone and trimethoprim/sulfamethoxazole, doxycycline + hydroxychloroquine and other treatment options. RESULTS: Follow-up data were obtained from 14 patients. The median follow-up was 46.5 months. All patients completed the antibiotic treatment prescribed, with a median duration of 13 months. Six patients were treated with ceftriaxone and trimethoprim/sulfamethoxazole (median duration 13 months), four with doxycycline + hydroxychloroquine (median duration 13.8 months) and four with other treatment options (median duration 22.3 months). The follow-up after the end of the treatments was between 5 and 84 months (median 24 months). CONCLUSIONS: All treatment lines were effective and well tolerated. Therapeutic failures were not detected during the treatment. None of the patients died or experienced a relapse during the follow-up. Only six patients received antibiotic treatment in accordance with guidelines. These data suggest that shorter antimicrobial treatments could be effective