Superficial keratectomy and 360º conjunctival flap for bullous keratopathy in a dog: a case report

Relata-se o caso ocorrido em um cão, da raça Pinscher, com dois anos de idade e histórico de desconforto no olho direito. O olho esquerdo havia sido enucleado por outro profissional, por apresentar os mesmos sinais, cujo tratamento clínico instituído não lograra êxito. O valor do teste da lágrima de Schirmer encontrava-se aumentado e identificou-se diminuição da pressão intraocular à tonometria de aplanação. Observaram-se, à biomicroscopia, edema corneal profuso e ceratocone, e o teste da fluoresceína foi negativo. Gonioscopia e oftalmoscopia não lograram fornecer dados relevantes dadas as condições da córnea. Diagnosticou-se ceratite bolhosa. Optou-se pelo tratamento cirúrgico, que fora realizado em duas etapas: 1- ceratectomia superficial e flap conjuntival de 360º; 2- ceratectomia superficial para devolver transparência à córnea. Transcorridos 30 dias da segunda ceratectomia superficial, o flap de terceira pálpebra foi desfeito. Observou-se conjuntivalização do quadrante nasal superior da córnea, córnea clara no eixo visual e retorno da visão.

Long-term graft survival in patients with flexible open-loop anterior chamber intraocular lenses

Purpose. To evaluate the long-term graft survival in patients with flexible open-loop anterior chamber intraocular lenses (AC IOL). Methods. We retrospectively reviewed the records of patients with aphakic/pseudophakic bullous keratopathy who underwent penetrating keratoplasty and flexible open-loop AC IOL implantation in our institution from 1983 to 1988. Results. 79 eyes from 77 patients were included in the study. Mean follow-up was 50 months (range 1 to 123 months). At last follow-up 61 eyes (77.2%) had clear grafts. Among them, the visual acuity was = 20/40 in 14 eyes (23.0%), 20/50-20/100 in 22 eyes (36.1%), 20/200-20/400 in 9 eyes (14.8%) and = CF in 16 (26.2%). Increment of glaucoma medications and/or glaucoma surgery was the most frequent complication (37 eyes, 46,8%). Cystoid macular edema was newly diagnosed in 10 eyes (12.7%). Conclusions. Flexible, open-loop anterior chamber lens are a viable option in the treatment of patients with aphakic or pseudophakic bullous keratopathy undergoing penetrating keratoplasty.

Eficácia e segurança da ceratoplastia endotelial no tratamento da ceratopatia bolhosa pseudofácia e afácia: revisão sistemática e metanálise

Pós-graduação em Bases Gerais da Cirurgia - FMB

Tied Out Open Sky technique: new method for iris fixation of intraocular lens in the absence of capsular support during penetrating keratoplasty

To describe a new method for iris fixation of intraocular lens in the absence of capsular support during penetrating keratoplasty. Its a new technique of iris fixation of intraocular lens without capsular support during penetrating keratoplasty. This technique is used in cases with a healthy iris and partial or total absence of capsular support during penetrating keratoplasty. Tied Out Open Sky is a technique easy to perform for iris fixation of intraocular lens during penetrating keratoplasty. The big advantage is being able to tie off the intraocular lens off the eye and fasten it securely.

Long-term graft survival in patients with flexible open-loop anterior- chamber intraocular lenses

Purpose. To evaluate the long-term graft survival and complications of flexible, open-loop anterior-chamber intraocular lenses in patients with penetrating keratoplasty for pseudophakic or aphakic bullous keratopathy. Methods. We reviewed charts of all consecutive patients who underwent penetrating keratoplasty for pseudophakic or aphakic bullous keratopathy combined with implantation of a flexible, open-loop, anterior-chamber intraocular lens at our institution between 1983 and 1988. One-hundred one eyes of 99 patients were evaluated. Graft-survival rates were calculated by using the Kaplan-Meier actuarial method. Results. Mean follow-up was 49.8 months (range. 1-144). The probability of graft survival at 1, 2, 4, 6, and 8 years was 93, 87, 78, 65, and 65%, respectively. A total of 25 (24.8%) grafts failed. Progressive corneal edema without signs of rejection was the most common finding in patients with failed grafts (10 eyes, 40%). The most frequent complication observed was newly diagnosed or worsening of preexisting glaucoma (46 eyes, 45.5%). Conclusions. Our long-term results support flexible, open-loop anterior-chamber intraocular lenses as a reasonable option, at the time of penetrating keratoplasty, in patients with pseudophakic and aphakic bullous keratopathy.

Standardised antibacterial Manuka honey in the management of persistent post-operative corneal oedema: A case series

Background Corneal oedema is a common post-operative problem that delays or prevents visual recovery from ocular surgery. Honey is a supersaturated solution of sugars with an acidic pH, high osmolarity and low water content. These characteristics inhibit the growth of micro-organisms, reduce oedema and promote epithelialisation. This clinical case series describes the use of a regulatory approved Leptospermum species honey ophthalmic product, in the management of post-operative corneal oedema and bullous keratopathy. Methods A retrospective review of 18 consecutive cases (30 eyes) with corneal oedema persisting beyond one month after single or multiple ocular surgical procedures (phacoemulsification cataract surgery and additional procedures) treated with Optimel Antibacterial Manuka Eye Drops twice to three times daily as an adjunctive therapy to conventional topical management with corticosteroid, aqueous suppressants, hypertonic sodium chloride five per cent, eyelid hygiene and artificial tears. Visual acuity and central corneal thickness were measured before and at the conclusion of Optimel treatment. Results A temporary reduction in corneal epithelial oedema lasting up to several hours was observed after the initial Optimel instillation and was associated with a reduction in central corneal thickness, resolution of epithelial microcysts, collapse of epithelial bullae, improved corneal clarity, improved visualisation of the intraocular structures and improved visual acuity. Additionally, with chronic use, reduction in punctate epitheliopathy, reduction in central corneal thickness and improvement in visual acuity were achieved. Temporary stinging after Optimel instillation was experienced. No adverse infectious or inflammatory events occurred during treatment with Optimel. Conclusions Optimel was a safe and effective adjunctive therapeutic strategy in the management of persistent post-operative corneal oedema and warrants further investigation in clinical trials.

Corneal toxicity and inflammation secondary to retained perfluorodecalin

PURPOSE: To describe a case with bullous keratopathy and anterior segment inflammation associated with heavy liquids. DESIGN: Observational case report. METHODS: Review of clinical and histopathologic changes. RESULTS: A 65-year-old patient underwent a pars plana vitrectomy for a rhegmatogenous retinal detachment. Perfluorodecalin was used as a temporary retinal tamponade. After surgery, bubbles of heavy liquid were noted in the anterior chamber. Fifteen months later, severe corneal edema developed, associated with corneal vascularization and keratic precipitates. Removal of heavy liquid through a paracentesis was attempted but the cornea remained edematous, and a penetrating keratoplasty was performed. In the histopathologic examination inflammatory changes from retention of perfluorodecalin were observed. There was a decompensated cornea with florid bullous keratopathy, inflammatory infiltration with vascularization, and deposition of perfluorodecalin within keratocytes and perivascular macrophages. CONCLUSION: Presence of heavy liquids in the anterior chamber may be associated with an intense inflammatory response and corneal decompensation. © 2005 by Elsevier Inc. All rights reserved.

Étude comparative de l'anatomie des plaies de greffe de cornée par tomographie de cohérence optique (OCT)

Cette thèse porte sur l’étude de l’anatomie de la cornée après 3 techniques de greffe soient, la greffe totale traditionnelle (GTT) et des techniques de greffe lamellaire postérieur (GLP) telles que la greffe lamellaire endothéliale profonde (DLEK) et la greffe endothélium/membrane de Descemet (EDMG) pour le traitement des maladies de l’endothélium, telles que la dystrophie de Fuchs et de la kératopathie de l’aphaque et du pseudophaque. Dans ce contexte, cette thèse contribue également à démontrer l’utilité de la tomographie de cohérence optique (OCT) pour l’étude de l’anatomie des plaies chirurgicales la cornée post transplantation. Au cours de ce travail nous avons étudié l'anatomie de la DLEK, avant et 1, 6, 12 et 24 mois après la chirurgie. Nous avons utilisé le Stratus OCT (Version 3, Carl Zeiss, Meditec Inc.) pour documenter l’anatomie de la plaie. L'acquisition et la manipulation des images du Stratus OCT, instrument qui à été conçu originalement pour l’étude de la rétine et du nerf optique, ont été adaptées pour l'analyse du segment antérieur de l’oeil. Des images cornéennes centrales verticales et horizontales, ainsi que 4 mesures radiaires perpendiculaires à la plaie à 12, 3, 6 et 9 heures ont été obtenues. Les paramètres suivants ont été étudiés: (1) Les espaces (gap) entre les rebords du disque donneur et ceux du receveur, (2) les dénivelés de surface postérieure (step) entre le les rebords du disque donneur et ceux du receveur, (3) la compression tissulaire, (4) le décollement du greffon, 6) les élévations de la surface antérieure de la cornée et 7) la pachymétrie centrale de la cornée. Les mesures d’épaisseur totale de la cornée ont été comparées et corrélées avec celles obtenues avec un pachymètre à ultra-sons. Des mesures d’acuité visuelle, de réfraction manifeste et de topographie ont aussi été acquises afin d’évaluer les résultats fonctionnels. Enfin, nous avons comparé les données de DLEK à celles obtenues de l’EDMG et de la GTT, afin de caractériser les plaies et de cerner les avantages et inconvénients relatifs à chaque technique chirurgicale. Nos résultats anatomiques ont montré des différences importantes entre les trois techniques chirurgicales. Certains des paramètres étudiés, comme le sep et le gap, ont été plus prononcés dans la GTT que dans la DLEK et complètement absents dans l’EDMG. D’autres, comme la compression tissulaire et le décollement du greffon n’ont été observés que dans la DLEK. Ceci laisse entrevoir que la distorsion de la plaie varie proportionnellement à la profondeur de la découpe stromale du receveur, à partir de la face postérieure de la cornée. Moins la découpe s’avance vers la face antérieure (comme dans l’EDMG), moins elle affecte l’intégrité anatomique de la cornée, le pire cas étant la découpe totale comme dans la GTT. Cependant, tous les paramètres d’apposition postérieure sous-optimale et d’élévation de la surface antérieure (ce dernier observé uniquement dans la GTT) finissent par diminuer avec le temps, évoluant à des degrés variables vers un profil topographique plus semblable à celui d’une cornée normale. Ce processus paraît plus long et plus incomplet dans les cas de GTT à cause du type de plaie, de la présence de sutures et de la durée de la cicatrisation. Les valeurs moyennes d’épaisseur centrale se sont normalisées après la chirurgie. De plus, ces valeurs moyennes obtenues par OCT étaient fortement corrélées à celles obtenues par la pachymétrie à ultra-sons et nous n’avons remarqué aucune différence significative entre les valeurs moyennes des deux techniques de mesure. L’OCT s’est avéré un outil utile pour l’étude de l’anatomie microscopique des plaies chirurgicales. Les résultats d’acuité visuelle, de réfraction et de topographie des techniques de GLP ont montré qu’il existe une récupération visuelle rapide et sans changements significatifs de l’astigmatisme, contrairement à la GTT avec et sans suture. La GLP a permis une meilleure conservation de la morphologie de la cornée, et par conséquence des meilleurs résultats fonctionnels que la greffe de pleine épaisseur. Ceci nous permet d’avancer que la GLP pourrait être la technique chirurgicale à adopter comme traitement pour les maladies de l’endothélium cornéen.

PVR recurrence and the timing of silicon oil removal

BACKGROUND: Following vitrectomy for PVR-associated retinal detachment, placement of an encircling band, filling with silicone oil (SO) and successful retinal reattachment, a recurrence of PVR can develop. Retinal redetachment after SO removal is usually due to secondary or residual PVR. We wanted to ascertain whether the anatomical and functional outcomes of surgery in patients with a reattached retina and recurrent PVR can be improved by delaying the removal of SO. PATIENTS AND METHODS: 112 consecutive patients with PVR-associated retinal detachment who had undergone vitrectomy with SO filling, were monitored for at least 6 months after SO removal. Prior to SO removal, the retina posterior to the encircling band had to be completely reattached. Patients who developed PVR after SO filling were divided into two groups according to the duration of SO retention: 12 - 18 months (group 2: n = 48); > 18 months (group 3: n = 21). Individuals without PVR recurrence after SO filling and in whom the SO was consequently removed within 4 - 12 months served as control (group 1: n = 43). Anatomical success, intraocular pressure (IOP) and best-corrected visual acuity (BCVA) served as the primary clinical outcome parameters. RESULTS: Six months after SO removal, the anatomical success rates (86.3 %, 88.8 % and 84.6 %, in groups 1, 2 and 3, respectively; log rank = 0.794) and the BCVAs (p = 0.861) were comparable in the three groups. Mean IOP (p = 0.766), and the frequency of complications such as PVR recurrence (p = 0.936), bullous keratopathy (p = 0.981) and macular pucker (p = 0.943) were likewise similar. Patients in whom SO was retained for more than 18 months had the highest IOPs and required the heaviest dosage with anti-glaucoma drugs. CONCLUSIONS: In patients who develop a recurrence of PVR after vitrectomy and SO filling the surgeon can observe and treat retinal changes for up to 18 months without impairing the anatomical and functional outcomes. The retention of SO for more than 18 months does not improve the anatomical outcome. However, it can impair the functional outcome by precipitating the development of a persisting secondary glaucoma.

Late reactivation of herpes zoster keratitis results in band keratopathy

Purpose To report an unusual case of a late-stage reactivation of immune stromal keratitis associated with herpes zoster ophthalmicus (HZO), occurring without any apparent predisposing factors, more than 4 years after an acute zoster dermatomal rash. Significant corneal hypoesthesia and a central band keratopathy developed within 6 months of the late-stage reactivation. The clinical case management, issues associated with management, and management options are discussed, including the use of standardized, regulatory approved, antibacterial medical honey. Case Report An 83-year-old woman presented for routine review with a reactivation of right anterior stromal keratitis and mild anterior uveitis, occurring more than 4 years after an acute HZO dermatomal rash and an associated initial episode of anterior stromal keratitis. Corneal sensation became markedly impaired, and over the subsequent 6 months, a right central band keratopathy developed despite oral antiviral and topical steroid therapy. Visual acuity with pinhole was reduced to 20/100 in the affected eye and moderate irritation and epiphora were experienced. The patient declined the surgical intervention options of chelation, lamellar keratectomy, and phototherapeutic keratectomy to treat the band keratopathy. Longer-term management has involved preservative-free artificial tears, eyelid hygiene, standardized antibacterial medical honey, topical nonpreserved steroid, and UV-protective wraparound sunglasses. The clinical condition has improved over 14 months with this ocular surface management regimen, and visual acuity of 20/30 is currently achieved in a comfortable eye. Conclusions The chronic and recurrent nature of HZO can be associated with significant corneal morbidity, even many years after the initial zoster episode. Long-term review and management of patients with a history of herpes zoster stromal keratitis are indicated following the initial corneal involvement. Standardized antibacterial medical honey can be considered in the management of the chronic ocular surface disease associated with HZO and warrants further evaluation in clinical trials.

Pseudophakic retinal detachment

Pseudophakic retinal detachment is a rare, but potentially serious, complication of cataract surgery. The incidence of pseudophakic retinal detachment following current surgical techniques of cataract extraction, including extracapsular cataract extraction by nuclear expression and phacoemulsification, is lower than that found after intracapsular cataract extraction. The risk of pseudophakic retinal detachment appears to be increased in myopic patients, in those patients in whom vitreous loss had occurred at the time of cataract surgery, and in patients undergoing Nd:YAG posterior capsulotomy. Most cases present to the clinician when the macula is already detached and the central vision is affected. When evaluating patients with pseudophakic retinal detachment, the fundal view is often impaired by anterior or posterior capsular opacification, reflections related to the intraocular lens, or poor mydriasis. Scleral buckling, pneumatic retinopexy, and primary pars plana vitrectomy, with or without combined scleral buckling, are the surgical techniques used to treat pseudophakic retinal detachment. Anatomical success rates are high after vitreo-retinal surgery for pseudophakic retinal detachment, although a smaller proportion of patients recover good vision following surgery. © 2003 Elsevier Inc. All rights reserved.

New surgical approach in the management of pseudophakic malignant glaucoma

Purpose: To describe a new surgical approach in the management of pseudophakic malignant glaucoma. Design: Noncomparative case series. Participants: Five consecutive patients with pseudophakic malignant glaucoma. Methods: All patients underwent zonulo-hyaloido-vitrectomy. The procedure involves the performance of zonulectomy, hyaloidectomy, and anterior vitrectomy (zonulo-hyaloido-vitrectomy) through a peripheral iridectomy or iridotomy via the anterior chamber. Main Outcome Measures: Medications, visual acuity, intraocular pressure, and anterior and posterior segment findings were recorded before and after surgery. Results: Resolution of the malignant glaucoma was achieved in all cases. No recurrences were observed after a median follow-up of 5.5 months (range, 1-9 months). In one patient with extensive anterior synechiae, bleb failure occurred after the resolution of the malignant glaucoma. This patient was treated successfully with a guarded filtration procedure supplemented with 5-fluorouracil. No other complications were observed. Conclusions: Zonulo-hyaloido-vitrectomy via the anterior segment appears to be an alternative option in the treatment of patients with pseudophakic malignant glaucoma. © 2001 by the American Academy of Ophthalmology.

Tono-Pen determination of intraocular pressure in patients with band keratopathy or glued cornea

Aims. To evaluate the intraocular pressure (IOP) measurements in patients with band keratopathy or glued corneas obtained from affected and non-affected areas. Methods. 15 patients with band keratopathy or glued corneas were prospectively recruited. When both eyes were affected, only the right eye was analysed. Tono-Pen readings of IOP were obtained sequentially from the affected and non-affected corneal surface. Additionally, Goldmann applanation tonometry was attempted. Results. Determination of IOP with the Tono-Pen was possible in all cases, while Goldmann tonometry was not performed in three patients because of severe corneal irregularities. The average of the Tono-Pen readings obtained from the affected cornea (34.8 (SD 14.0) mmHg) was consistently and significantly higher (p <0.001) than mean IOP obtained by the Tono-Pen from the non-affected area (14.8 (4.3) mmHg). The average of Goldmann tonometry readings (14.4 (6.1) mmHg) did not differ significantly from the Tono-Pen values obtained from the non-affected corneal area (p = 0.47) but was significantly lower than the Tono-Pen measurements obtained from the affected area (p <0.001) Conclusion. In patients with band keratopathy or glued corneas determination of IOP by Tono-Pen tonometry varies from affected to non-affected area. The Tono-Pen overestimates the level of IOP when it is applied to areas with band keratopathy or with glue.