Bilateral Corneal Perforation in a Patient with Chronic Ocular Graft-Versus-Host Disease: A Case Report and Literature Review

Graft-versus-host disease (GVHD) is a serious complication that may occur in patients receiving allogeneic hematopoietic stem cell transplant (HSCT). GVHD occurs because of the immunological reaction between the donor’s T cells and the recipient’s antigens; GVHD may develop in different tissues, including the eye. Corneal perforation is an uncommon but vision-threatening manifestation of GVHD. We reported the case of a 65-year-old male patient who developed corneal perforation sequentially in both eyes 3 years after receiving HSCT. Conservative treatment with topical steroids and lubricants, bandage contact lens, and lacrimal punctal occlusion surgery resulted in the successful resolution of the corneal perforation with satisfactory visual recovery in the right eye. Therefore, corneal perforation can occur as the presenting manifestation of ocular GVHD. Regular ophthalmological examinations are recommended after HSCT to enable the early diagnosis of ocular GVHD and prompt treatment initiation

Intravitreal Dexamethasone Implant in Patients Who Did Not Complete Anti-VEGF Loading Dose During the COVID-19 Pandemic: a Retrospective Observational Study

Introduction To compare the functional and anatomic outcomes between eyes in patients with diabetic macular edema (DME) who underwent a complete anti-vascular endothelial growth factor (VEGF) loading dose with aflibercept and those who were switched to dexamethasone intravitreal (DEX) implant after an incomplete anti-VEGF treatment regimen during the coronavirus disease 2019 (COVID-19) pandemic. Methods This was a retrospective and comparative study conducted on patients with DME. Main outcome measures were mean change in best corrected visual acuity (BCVA) and central retinal thickness (CRT) from baseline to month 4. Results Forty-three eyes (23 eyes in the anti-VEGF group and 20 eyes in the DEX group) were included. Mean BCVA significantly improved from 37.7 +/- 25.3 and 35.7 +/- 22.0 letters at baseline to 45.4 (23.9) (mean adjusted BCVA improvement 7.6 +/- 20.8 letters, p = 0.033) and 46.1 +/- 26.0 (mean adjusted BCVA improvement 10.6 +/- 15.9 letters, p = 0.049) at month 4 in the anti-VEGF and DEX groups, respectively, with no significant differences between study groups (mean adjusted BCVA difference 2.8 letters, 95% CI - 9.4 to 14.9 letters, p = 0.648). There were no statistically significant differences in the proportion of eyes that achieved a BCVA improvement of >= 5, >= 10, and >= 15 letters between groups. CRT was significantly reduced from baseline to month 4 in both DEX (mean adjusted CRT reduction 167.3 +/- 148.2 mu m, p = 0.012) and anti-VEGF groups (mean adjusted CRT reduction 109.9 +/- 181.9 mu m, p < 0.001), with no differences between them (mean adjusted CRT difference 56.1 mu m, 95% CI - 46.0 to 158.2 mu m, p = 0.273). Of 20 eyes in the DEX group, 16 (80.0%) and 9 (45.0%) eyes achieved a CRT reduction of >= 20% from baseline at 2 months and at 4 months, respectively. Conclusions Our results seem to suggest that DEX implant can significantly improve both functional and anatomic clinical outcomes in patients who were unable to complete anti-VEGF loading dose during the COVID-19 pandemic

Pentacam Assessment of Posterior Lamellar Grafts to Explain Hyperopization after Descemet's Stripping Automated Endothelial Keratoplasty

Purpose: To evaluate changes in posterior corneal curvature as a possible cause of the hyperopic refractive shift observed after Descemet's stripping automated endothelial keratoplasty (DSAEK). Design: Prospective, noncomparative, interventional case series. Participants: Thirty-four eyes of 29 patients with Fuchs' endothelial dystrophy or pseudophakic bullous keratopathy. Methods: A standard DSAEK procedure was performed in 34 eyes using the pull-through technique for graft delivery. When cataract was present (n = 7), phacoemulsification with posterior chamber intraocular lens implantation was combined. Each eye underwent Pentacam (Oculus, Wetzlar, Germany) evaluation 1, 3, and 12 months after surgery. Corneal graft thickness was calculated on Scheimpflug scans at 9 locations (1 central, 4 peripheral, and 4 mid peripheral). The mean radius of posterior corneal curvature (Rm) was recorded. At each postoperative examination time, manifest refraction was determined and compared with pre-DSAEK values in simple procedures or with intended postoperative refraction, if cataract surgery had been performed. Main Outcome Measures: Manifest refraction, Rm, and corneal graft thickness at 1, 3, and 12 months after surgery. Results: The mean±standard deviation posterior corneal curvature was 6.5±0.56 mm before surgery and varied from 5.52±0.39 mm 1 month after surgery to 5.83±0.37 mm at 3 months after surgery and 5.92±0.35 mm at 12 months after surgery. The grafts were significantly thicker in the periphery and mid periphery than in the center at all examination times. Thickening diminished significantly over time at all locations. The average reduction of corneal thickness was higher at the edges (91.5 μm) than in the mid periphery (38.3 μm) or in the center (24.2 μm). The average postoperative spherical equivalent±standard deviation changed from -0.31±2.35 diopters (D) before surgery to 1.03±2.21 D 1 month after surgery, 0.61±2.07 D 3 months after surgery, and +0.31±2.03 D 12 months after surgery. Conclusions: The difference in thickness between center and periphery of the DSAEK graft induces a change in posterior corneal curvature, resulting in a hyperopic shift that decreases with time and is negligible for spectacle correction. However, when performing a triple procedure, intraocular lens selection should take into account the refractive change induced by DSAEK. Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references. © 2009 American Academy of Ophthalmology

Survival of mushroom keratoplasty performed in corneas with postinfectious vascularized scars

To report the visual outcomes and graft survival rates of mushroom keratoplasty for the treatment of postinfectious corneal scars. Prospective, noncomparative, interventional case series. A microkeratome-assisted mushroom-shaped keratoplasty was performed in 31 eyes of 31 patients with a central vascularized full-thickness leukoma, resulting from infectious keratitis of various origin (herpes simplex virus, n = 16; bacteria, n = 10; Acanthamoeba, n = 5), with healthy endothelium. The donor graft consisted of a large anterior stromal lamella (9.0 mm in diameter and ± 250 μm in thickness) and a small posterior button (5 to 6 mm in diameter). Visual acuity, refraction, and endothelial cell density were evaluated before surgery, as well as at 12, 24, and 36 months after surgery, and the postoperative graft survival rate was evaluated. Three years after surgery, in 26 (83.8%) of 31 patients, best spectacle-corrected visual acuity was 20/40 or better with a refractive astigmatism of 4.5 diopters or less. The endothelial cell count at the last follow-up examination averaged 1584 ± 381 cells/mm2, with an average cell loss of 40.7% from the preoperative value. The survival rate at 3 years was 90.3%, improving to 96.7% when excluding nonimmunologic causes for graft failure. Similarly to penetrating keratoplasty, microkeratome-assisted mushroom keratoplasty restores vision in eyes with postinfectious, full-thickness, central corneal scars. For these vascularized corneas at high risk for immunologic rejection, mushroom keratoplasty combines the visual and refractive advantages of large penetrating keratoplasty grafts with the high survival rate of small penetrating keratoplasty grafts. © 2012 By Elsevier Inc. All Right Reserved

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Red Reflex-Guided Big-Bubble Deep Anterior Lamellar Keratoplasty: A Simple Technique to Judge Dissection Depth

Purpose: To report the results of a modified big-bubble deep anterior lamellar keratoplasty technique using the intraoperative red reflex to visualize the amount of residual stroma beneath the inserted cannula. Methods: A total of 132 consecutive keratoconic eyes were included in this retrospective, noncomparative, interventional case series. Before starting surgery, pharmacologic mydriasis was induced in all eyes undergoing a big-bubble deep anterior lamellar keratoplasty procedure. After partial trephination of the recipient cornea, a spatula was inserted at the base of the incision and advanced into depth using as a reference the thin dark line seen in the red reflex ahead of the advancing tip; the stromal depth reached was measured using anterior segment optical coherence tomography. Finally, the spatula was exchanged for a 27-gauge cannula, and air was injected to create a big bubble. The stromal depth reached with the spatula, success rate of big-bubble formation, and complications were recorded. Results: The big bubble was obtained in 118 of 132 eyes (89.4%). Of the remaining 14 eyes, 11 underwent completion of the procedure by manual dissection and 3 were converted to penetrating keratoplasty because the bubble burst while trying to enlarge it. Perforation did not occur in any case during cannula insertion. The average thickness reached with the stromal dissection was 64.3 ± 19.5 m. Conclusions: The thin dark line, seen in the red reflex obtained with pharmacologic dilation, provides a useful and effective reference that can be used to visualize and judge the depth of dissection, thus allowing a safer and reproducible approach to the pre-Descemetic stroma. Â

Surgical technique for graft exchange after big-bubble deep anterior lamellar keratoplasty

Purpose: The aim of this study was to describe a surgical technique for repeat deep anterior lamellar keratoplasty (DALK) by baring Descemet membrane again in eyes affected by stromal opacity of the donor lamella. Methods: Repeat DALK was performed in 5 eyes of 5 patients affected by central stromal opacity not involving the endothelium; indications for repeat surgery were postbacterial or postherpetic corneal scars (n = 3), postphotorefractive keratectomy haze (n = 1), and recurrence of granular dystrophy (n = 1). The surgical procedure consisted of the following: (1) superficial trephination, 250 mm in depth, on the original peripheral scar; (2) blunt detachment of the donor graft completed by means of corneal forceps; (3) apposition of the new lamella. Best spectacle-corrected visual acuity, topographic astigmatism, and endothelial cell density were evaluated preoperatively, as well as 3, 6, 9, 12, and 18 months after surgery. Results: At the latest follow-up examination, with all sutures removed from all eyes, the best spectacle-corrected visual acuity was 20/30 or better in all cases with 3 eyes achieving 20/20. Postoperative refractive astigmatism averaged 3.0 6 1.2 diopters (mean 6 SD); endothelial cell density was not significantly affected by surgery. Conclusions: Repeat DALK is effective in removing diseased corneal stroma while keeping the recipient endothelium unaffected; the procedure is simple and does not require pneumatic dissection, thus eliminating the most challenging surgical step; postoperative visual recovery does not differ from that experienced after primary DALK

Anterior segment optical coherence tomography-guided big-bubble technique

Purpose: To evaluate the feasibility of intraoperative anterior segment (AS) optical coherence tomography (OCT) for quantification of the corneal depth reached with the dissecting cannula used for deep anterior lamellar keratoplasty, as well as its correlation with the success rate of big-bubble formation. Design: Retrospective, noncomparative, interventional case series. Participants: One hundred consecutive keratoconus patients. Intervention: Deep anterior lamellar keratoplasty was performed using the big-bubble technique. During surgery, the cannula used for pneumatic dissection was inserted into the peripheral stroma and advanced as deep and far toward the center as believed adequate by the surgeon. Then, after retracting the cannula, AS OCT was performed. The cannula was placed back in position and creation of the big bubble was attempted. Main Outcome Measures: Stromal depth reached with the cannula tip, success rate in achieving big-bubble formation, and complication rate. Results: Bubble formation was obtained in 70 of 100 eyes (70%). In all remaining eyes, the procedure was completed by manual deep lamellar dissection. The average depth reached by the cannula tip was 104.3±34.1 μm from the internal corneal surface; the mean value recorded in cases of successful big-bubble formation (90.4±27.7 μm) was statistically lower than that measured in failed procedures (136.7±24.2 μm). In 1 case, corneal perforation occurred during the insertion of the cannula and required conversion to penetrating keratoplasty (PK). In 8 eyes, small microperforations occurred during stromal excision but could be managed conservatively, avoiding conversion to PK. In 2 advanced cones, an incomplete bubble formation was obtained, necessitating manual peripheral stromal removal. Conclusions: Successful big-bubble formation can be anticipated if pneumatic dissection is attempted at a sufficiently deep level. Although an ideal depth could not be defined, AS OCT allows objective evaluation of the depth reached by the cannula tip used for pneumatic dissection. The AS OCT findings may confirm the decision to proceed with air injection. It is possible that cannula repositioning based on the AS OCT depth may improve the success rate for big-bubble formation. Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references. © 2013 American Academy of Ophthalmology

Small-bubble deep anterior lamellar keratoplasty technique

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