AIM:To compare visual,surgical and topographic outcomes of deep anterior lamellar keratoplasty(DALK)and penetrating keratoplasty(PK)for keratoconus(KC).METHODS:In this multicenter,prospective,randomized clinical trial...AIM:To compare visual,surgical and topographic outcomes of deep anterior lamellar keratoplasty(DALK)and penetrating keratoplasty(PK)for keratoconus(KC).METHODS:In this multicenter,prospective,randomized clinical trial 76 eyes of 71 KC patients operated between January 2011 and July 2014 in 2 tertiary referral hospitals were included. Consecutive patients were alternately selected to receive one of the two surgical methods. Thirty eight eyes underwent DALK with the big-bubble technique and 38 eyes underwent PK.RESULTS:Mean best spectacle corrected visual acuity(BSCVA)at the first postoperative week(P=0.012)and the first postoperative month(P<0.001)was statistically significantly higher in DALK group. The mean BSCVA at12 mo was not significantly different for DALK(0.30±1.99 log MAR)versus PK(0.40±0.33 log MAR)(P=0.104). The76.3% of the eyes had a BSCVA over 0.5 in DALK and 47.4%in PK group(P=0.009). The 7.9% of the eyes had a BSCVA of 1.0 in DALK and 5.3% in PK group(P=0.644). Mean spherical equivalent was-2.94 D in DALK and-3.09 D in PK group.Mean topographic astigmatism was 4.62 D and 4.18 D respectively. Regular topographic patterns were observed in 31(81.6%)of DALK and 29(76.3%)of PK(P=0.574). The most frequent topographic pattern was oblate asymmetric bow tie,seen in 39.5% in DALK and 23.7% in PK. CONCLUSION:Big bubble DALK provides an earlier visual improvement compare to PK. However,visual and topographic outcomes are similar to those in PK at 1y. Postoperative complications including rejection and intraocular pressure elevation are more frequent in PK. DALK is a safer alternative to PK for KC. However,intraoperativeperforation of the Descemet's membrane is a significant complication.展开更多
AIM:To analyze the changing trends in penetrating keratoplasty(PKP)indications.METHODS:This retrospective study included all patients with PKP between 2006 and 2017.Patients were classified using histological diagnose...AIM:To analyze the changing trends in penetrating keratoplasty(PKP)indications.METHODS:This retrospective study included all patients with PKP between 2006 and 2017.Patients were classified using histological diagnoses.Our groups were as the following:pseudophakic or aphakic bullous keratopathy,regraft,acute necrotizing and ulcerative keratitis,keratoconus,Fuchs'dystrophy,corneal dystrophy other than Fuchs',corneal scar,other diagnoses and failed endothelial keratoplasty graft.Additionally,two different time-periods(2006-2012 and 2013-2017)were analysed.RESULTS:Totally 1721 histological analyses of 1214 patients were available for review.The diagnoses were pseudophakic or aphakic bullous keratopathy in 487(28.3%),regraft in 443(25.7%),acute necrotizing and ulcerative keratitis in 313(18.2%),corneal scar in 153(8.9%),keratoconus in 140(8.1%).Fuchs'dystrophy in 61(3.5%),corneal dystrophy other than Fuchs'in 46(2.7%),other diagnoses in 44(2.6%)and failed endothelial keratoplasty graft in 34(2.0%)cases.From the first to the second analysed time-period,incidence of acute necrotizing and ulcerative keratitis,corneal scar,Fuchs'dystrophy increased(P<0.032 for all)and incidence of keratoconus significantly decreased(P=0.015).CONCLUSION:Pseudophakic or aphakic bullous keratopathy is the leading indication for PKP,followed by regraft and acute necrotizing and ulcerative keratitis.展开更多
AIM: To review the indications of penetrating keratoplasty(PK) and anterior lamellar keratoplasty(ALK) at Qingdao Eye Hospital, Shandong Eye Institute, Qingdao, China, from 2010 to 2017. METHODS: The data of all patie...AIM: To review the indications of penetrating keratoplasty(PK) and anterior lamellar keratoplasty(ALK) at Qingdao Eye Hospital, Shandong Eye Institute, Qingdao, China, from 2010 to 2017. METHODS: The data of all patients undergoing PK or ALK from January 2010 to December 2017 was retrospectively reviewed, with the indications during 2010-2013 and 2014-2017 compared. RESULTS: A total of 1869 eyes were included, among which 1405 eyes(75.2%) had PK and 464 eyes(24.8%) had ALK. The leading indications were suppurative keratitis(36.8%), keratoconus(15.5%), herpes keratitis(13.1%), and regraft(10.5%). In eyes undergoing PK, the top four indications were suppurative keratitis(38.7%), herpes keratitis(15.3%), keratoconus(12.6%), and regraft(12.5%) during 2014-2017, with the proportion of suppurative keratitis and herpes keratitis decreased while regraft and keratoconus increased compared with 2010-2013. In eyes with ALK, suppurative keratitis(30.8%), keratoconus(24.1%), corneal dystrophies and degenerations(10.6%), and corneal dermoid tumor(9.7%) were the top four indications, and there was no significant difference for the proportion of each indication between 2010-2013 and 2014-2017. CONCLUSION: Suppurative keratitis is the most common indication for PK and ALK at Qingdao Eye Hospital during 2010-2017, followed by keratoconus, herpes keratitis, and regraft. In eyes treated with PK, the proportion of suppurative keratitis and herpes keratitis decrease while regraft and keratoconus increase during 2014-2017 compared with 2010-2013.展开更多
Dear Editor,I am Dr.Jo?o Beato,from the Ophthalmology Department of Sao Jo?o Hospital Center,Porto,Portugal.I write to present a case of combined penetrating keratoplasty(PKP)with temporary Eckardt keratoprosthesis,pa...Dear Editor,I am Dr.Jo?o Beato,from the Ophthalmology Department of Sao Jo?o Hospital Center,Porto,Portugal.I write to present a case of combined penetrating keratoplasty(PKP)with temporary Eckardt keratoprosthesis,pars plana vitrectomy(PPV)and Ahmed glaucoma valve(AGV)implantation into the ciliary sulcus in a patient with previous history of展开更多
AIM:To evaluate the midterm outcomes of penetrating keratoplasty(PK)following allogeneic cultivated limbal epithelial transplantation(CLET)for bilateral total limbal stem cell deficiency(LSCD).METHODS:Ten patients(10 ...AIM:To evaluate the midterm outcomes of penetrating keratoplasty(PK)following allogeneic cultivated limbal epithelial transplantation(CLET)for bilateral total limbal stem cell deficiency(LSCD).METHODS:Ten patients(10 eyes)with bilateral LSCD were enrolled in this prospective noncomparative case series study.Each participant underwent PK approximately 6 mo after a CLET.Topical tacrolimus,topical and systemic steroids,and oral ciclosporin were administered postoperatively.Best-corrected visual acuity(BCVA),intraocular pressure(IOP),ocular surface grading scores(OSS),corneal graft epithelial rehabilitation,persistent epithelial defect(PED),immunological rejection,and graft survival rate were assessed.RESULTS:The time interval between PK and allogeneic CLET was 6.90±1.29(6-10)mo.BCVA improved from 2.46±0.32 log MAR preoperatively to 0.77±0.55 log MAR post-PK(P<0.001).Kaplan-Meier analysis of mean graft survival revealed graft survival rates of 100%at 12 and 24 mo and 80.0%at 36 mo.PEDs appeared in 5 eyes at different periods post-PK,and graft rejection occurred in 4 eyes.The total OSS decreased from 12.4±4.4 before allogeneic CLET to 1.4±1.51 after PK.CONCLUSION:A sequential therapy design of PK following allogeneic CLET can maintain a stable ocular surface with improved BCVA despite the relatively high graft rejection rate.展开更多
AIM:To evaluate the graft rejection and visual outcomes after penetrating keratoplasty(PK)in the presence of various congenital corneal opacities in children.METHODS:In this retrospective cohort study,children who und...AIM:To evaluate the graft rejection and visual outcomes after penetrating keratoplasty(PK)in the presence of various congenital corneal opacities in children.METHODS:In this retrospective cohort study,children who underwent PK were then followed for 5 y.The patient’s medical records were collected from June 2014 until June 2019 and analyzed in December 2019.All patients were children under three years old with congenital corneal opacities with or without microcornea who came to a pediatric ophthalmologist and underwent PK in Jakarta Eye Center(JEC).Beforehand,all children have participated in a thorough evaluation for PK.In the case of severe microcornea was not advised to undergo surgery.The visual outcomes and graft survival rate were described in percentages.The graft survival plot was presented with Kaplan-Meier,while the visual acuity was analyzed using the Wilcoxon signed ranks test.RESULTS:Sixteen eyes from eleven patients(seven girls and four boys)underwent PK.The graft survival rate of the first 6,12,and 18 mo later of keratoplasty was 100%,83.3%,and 66.7%,respectively.The overall mean survival time is 22 mo(standard error 2.419),and no significant difference between the patients underwent PK before and after 36 mo of their age(P=0.52).The graft failure was 50%,and postsurgery complications included cataract 43.7%,band keratopathy 12.5%,and scleromalasia 6.25%.Wilcoxon test analysis of visual acuity post keratoplasty was not statistically significant(P=0.34),while overall showed 44%improvements of visual outcome for 5 y of follow-up.With a good survival at one year up to 22 mo(83.3%),the visual acuity could be achieved(63%),and showed improvements(44%)during follow-up.CONCLUSION:The complications are frequent for pediatric PK.Thus,corneal surgery on infants requires careful case selection,adequate pre-operative evaluation,skilled surgery(optical correction),very close cooperation family–physician,intensive post-operation care,and amblyopia management in the future.展开更多
Deep anterior lamellar keratoplasty(DALK) has recently been introduced as an alternative procedure to penetrating keratoplasty(PK) for corneal pathologies not affecting the corneal endothelium. DALK does not rely on d...Deep anterior lamellar keratoplasty(DALK) has recently been introduced as an alternative procedure to penetrating keratoplasty(PK) for corneal pathologies not affecting the corneal endothelium. DALK does not rely on donor endothelium and requires less rigid criteria for donor corneal tissue quality. Therefore, DALK makes it possible to use donor corneas deemed unsuitable for PK. Furthermore, lamellar keratoplasty allows acellular corneal tissue to be transplanted. As a result, long-term preservation techniques are being revisited to increase the availability of donor corneas and subsequently alleviate constraints of availability, cost, storage, and transportation in many countries. The recent alterations in corneal transplantation techniques and hence the type of donor cornea tissues used for each technique, may require corneal surgeons and eye banks to reevaluate their selection criteria. The purpose of this systematic review is to present an updated analysis on the type and quality of donor corneas used for PK and DALK, assess the influence of donor and eye bank factors on the quality of donor corneas, and determine whether any of these donor factors affect clinical outcomes, complications, and graft survivals.展开更多
Background: Keratoglobus is a rare noninflammatory corneal disorder characterized by diffuse corneal thinning and globular protrusion of the cornea. Surgical management of keratoglobus is challenging and the standard ...Background: Keratoglobus is a rare noninflammatory corneal disorder characterized by diffuse corneal thinning and globular protrusion of the cornea. Surgical management of keratoglobus is challenging and the standard method has not yet been defined. Aim: To present the role of large penetrating keratoplasty (PK) in the management of keratoglobus. Case Presentation: A 29-year-old male patient with bilateral keratoglobus presented with acute corneal hydrops in his right eye following extensive Descemet’s membrane rupture, with a visual acuity in this eye limited to hand movement. Peripheral cornea was extremely thin and blue sclera was present. Acute hydrops was managed conservatively at this stage and two months later large PK was performed in the right eye using 9.5 mm diameter graft over a 9 mm patient’s cornea trephination. Minor aqueous leakage was seen on the first postoperative day, managed with 2 more interrupted 10.0 nylon sutures. No further complications were noticed and postoperative course was uneventful. Fifteen months postoperatively the graft was clear and best corrected visual acuity was 20/60. Conclusions: Large penetrating keratoplasty has an important role in the management of keratoglobus, in cases where peripheral tuck-in lamellar keratoplasty or epikeratoplasty present serious intraoperative difficulties in host lamellar dissection and in stabilizing the graft due to extensive peripheral corneal and scleral thinning.展开更多
This paper shows how a public eye and research hospital in Turkey initiated Six Sigma principles to reduce the number of complications occurring after penetrating keratoplasty surgeries. Data were collected for nine y...This paper shows how a public eye and research hospital in Turkey initiated Six Sigma principles to reduce the number of complications occurring after penetrating keratoplasty surgeries. Data were collected for nine years. To analyse the complications among 55 patients (59 eyes) underwent penetrative keratoplasty, main tools of Six Sigma’s Define-Measure-Analyze-Improve-Control (DMAIC) improvement cycle such as SIPOC table and Failure, Mode and Effect Analysis (FMEA) were implemented. Sources and root causes of eleven types of complications were identified and reported. For a successful penetrating keratoplasty surgery patient’s anatomy, suitability of donor cornea, experience of ophthalmic surgeon, sterilization and hygiene, and performance of the equipment were determined to be the “critical-to-quality” factors. The complication with the highest hazard score was found to be the glaucoma. The process sigma level of the process was measured to be 3.1418. The surgical team concluded that all types of post-operative complications should be significantly reduced by taking the necessary preventive measures.展开更多
Objective: To compare postoperative outcomes of full-bed deep anterior lamellar keratoplasty (DALK) with penetrating keratoplasty (PK) in treating keratoconus. Methods: Seventy-five eyes of 64 patients who received fu...Objective: To compare postoperative outcomes of full-bed deep anterior lamellar keratoplasty (DALK) with penetrating keratoplasty (PK) in treating keratoconus. Methods: Seventy-five eyes of 64 patients who received full-bed DALK and 52 eyes of 51 patients who received PK between June 2000 and August 2010 were included in this retrospective study. Full-bed DALK was performed using Yao's hooking-detaching technique. PK was performed using a standard technique. Intraoperative and postoperative complications, visual acuity, rejection, graft survival, endothelial cell density, corneal sensation recovery, and re-innervation were compared between the two groups. Results: A best correct visual acuity of 0.5 or better was achieved in 90.7% of eyes after full-bed DALK and in 92.3% of eyes after PK (P=0.75). By the fifth postoperative year, graft endothelial cell loss reached 34.6% in the PK group vs. 13.9% in the full-bed DALK group (P<0.001). There were no statistical differences in corneal sensitivity recovery or corneal re-innervation between the groups (P>0.05). Intraoperative microperforation occurred in seven out of 75 (9.3%) eyes with a temporally postoperative double anterior chamber in two eyes in the full-bed DALK group. Postoperative complications in the PK vs. the full-bed DALK groups respectively were: rejection (7.7% vs. 0%, P=0.015), high intraocular pressure (IOP) (46.2% vs. 1.3%, P<0.001), secondary glaucoma (9.6% vs. 0%, P=0.006), complicated cataract (19.2% vs. 0%, P<0.001), and wound dehiscence (9.6% vs. 0%, P=0.006). Conclusions: Both full-bed DALK and PK can offer long-term satisfactory visual outcomes for keratoconus. Graft rejection, secondary glaucoma, complicated cataracts, and constant endothelial cell loss were observed in eyes only after PK.展开更多
Background:To report a surgical method for treating corneal oedema in a case of late-onset Descemet membrane detachment after penetrating keratoplasty.Case presentation:A 55-year old patient presented with sudden visu...Background:To report a surgical method for treating corneal oedema in a case of late-onset Descemet membrane detachment after penetrating keratoplasty.Case presentation:A 55-year old patient presented with sudden visual loss in his left eye 28 years after penetrating keratoplasty for keratoconus.Slit-lamp biomicroscopy revealed a distortion of the corneal graft anatomy with protrusion of the graft and peripheral thinning and steepening in the residual host tissue,accompanied by corneal graft oedema.Anterior segment optical coherence tomography revealed detachment of Descemet membrane localized to the area of the graft oedema.We proceeded with a full-thickness,partially circumferential incision in the graft-host junction,followed by repositioning and re-suturing of the graft in place,and intracameral air injection in order to achieve reattachment of Descemet membrane.Conclusions:Corneal graft repositioning in combination with re-bubbling may represent an effective therapeutic option in keratoconic patients with peripheral thinning in the residual host corneal tissue and subsequent Descemet membrane detachment.展开更多
AIM:To report the outcomes of three cases of corneal perforation managed with simultaneous tectonic Descemet stripping endothelial keratoplasty(t-DSEK)and tectonic Bowman layer transplant(t-BLT)as an alternative to te...AIM:To report the outcomes of three cases of corneal perforation managed with simultaneous tectonic Descemet stripping endothelial keratoplasty(t-DSEK)and tectonic Bowman layer transplant(t-BLT)as an alternative to tectonic penetrating keratoplasty(t-PKP).METHODS:Three eyes of three patients receiving simultaneous t-DSEK and t-BLT for corneal perforation were included.The technique for DSEK was modified depending on individual requirements.The t-BLT technique was standardised using an 8 mm graft and fixated with a running suture.Success was measured by the ability of this procedure to close a corneal perforation.RESULTS:All three cases achieved tectonic eye globe restoration and remained stable during the minimum 3-month observation period.Reinterventions were relatively common:2 cases required amniotic membrane transplant for persistent epithelial defects.One case required DSEK rebubbling.One case developed angle closure glaucoma requiring surgical peripheral iridectomy.CONCLUSION:Simultaneous t-DSEK and t-BLT may be a useful strategy for the management of corneal perforation as an alternative management to t-PKP for selected cases.展开更多
AIM: To report the fungal organisms, clinical features,surgical treatment strategies, and outcomes of patients with culture-proven exogenous fungal endophthalmitis(EFE) secondary to keratitis, and evaluate the role of...AIM: To report the fungal organisms, clinical features,surgical treatment strategies, and outcomes of patients with culture-proven exogenous fungal endophthalmitis(EFE) secondary to keratitis, and evaluate the role of surgery in the treatment.METHODS: The clinical records of 27 patients(27 eyes)with culture-proven EFE resulting from fungal keratitis treated at Shandong Eye Institute from January 2007 to January 2015 were retrospectively reviewed. Information about fungal culture results, clinical features, surgical procedures, and final visual acuity was obtained.RESULTS: There were 39 positive culture results from samples of cornea, hypopyon, vitreous and lens capsule,accounting for 56%, 26%, 15% and 2.5%, respectively.Fusarium was identified in 44%(12/27) of the eyes,followed by Aspergillus in 22%(6/27). Posterior segment infection was involved in 78%(21/27) of the patients. The corneal infection was larger than 3 mm×3 mm in 89%(24/27) of the patients, and 22%(6/27) of them had the entire cornea, and even the sclera involved. Three eyes had silicone oil tamponade, and two eyes had retinal detachment. Twenty-two eyes(81.5%) underwent penetrating keratoplasty(PKP), and over half of them(54.5%)were operated within 3d from the onset of antifungal therapy. Fourteen eyes(52%) underwent intracameral antifungal drug injection, and three of them required repeated injections. Fifteen eyes(55.6%) underwent pars plana vitrectomy(PPV). The rate of the eyes undergoing PPV as the initial surgical procedure was 60%(9/15),lower than 77% in PKP. Intravitreal injection was given in 59% of the eyes(16/27), and 75% of them required repeated injections. The final visual acuity was 20/100 or better in 37% of the eyes, and better than counting fingers in 55.6% of the eyes. Five eyes(18.5%) were eviscerated. In the two eyes with concurrent retinal detachment, one achieved retinal reattachment, and the other was eviscerated. In the three eyes with silicone oil tamponade, two eyes received silicone oil removal, and the other one was eviscerated. CONCLUSION: Fusarium and Aspergillus are the dominant pathogens in EFE resulting from keratitis.Aggressive antifungal surgeries including multiple intravitreal injections, PKP and core vitrectomy(especially in the initial surgery) are helpful procedures to improve prognosis of severe EFE secondary to keratitis.展开更多
Macular corneal dystrophy(MCD)is a progressive,bilateral stromal dystrophic disease that arises from mutations in carbohydrate sulfotransferase 6(CHST6).Corneal transplantation is the ultimate therapeutic solution for...Macular corneal dystrophy(MCD)is a progressive,bilateral stromal dystrophic disease that arises from mutations in carbohydrate sulfotransferase 6(CHST6).Corneal transplantation is the ultimate therapeutic solution for MCD patients.Unfortunately,postoperative recurrence remains a significant challenge.We conducted a retrospective review of a clinical cohort comprising 102 MCD patients with 124 eyes that underwent either penetrating keratoplasty(PKP)or deep anterior lamellar keratoplasty(DALK).Our results revealed that the recurrence rate was nearly three times higher in the DALK group(39.13%,9/23 eyes)compared with the PKP group(10.89%,11/101 eyes),suggesting that surgical replacement of the corneal endothelium for treating MCD is advisable to prevent postoperative recurrence.Our experimental data confirmed the robust m RNA and protein expression of CHST6 in human corneal endothelium and the rodent homolog CHST5 in mouse endothelium.Selective knockdown of wild-type Chst5 in mouse corneal endothelium(AC^(siChst5)),but not in the corneal stroma,induced experimental MCD with similar extracellular matrix synthesis impairments and corneal thinning as observed in MCD patients.Mice carrying Chst5 point mutation also recapitulated clinical phenotypes of MCD,along with corneal endothelial abnormalities.Intracameral injection of wild-type Chst5 rescued the corneal impairments in AC^(siChst5)mice and retarded the disease progression in Chst5 mutant mice.Overall,our study provides new mechanistic insights and therapeutic approaches for MCD treatment by highlighting the role of corneal endothelium in MCD development.展开更多
Postoperative visual acuity can be limited by post-keratoplasty astigmatism,even with a clear corneal graft.Astigmatism management can be performed by selective suture removal,adjustment of sutures,optical correction,...Postoperative visual acuity can be limited by post-keratoplasty astigmatism,even with a clear corneal graft.Astigmatism management can be performed by selective suture removal,adjustment of sutures,optical correction,photorefractive procedures,wedge resection,intra-ocular lens implantation,intracorneal ring segments,relaxing incisions with or without compression sutures and repeated keratoplasty.Relaxing incisions can be made in the graft,graft-host interface or host cornea.Despite the unpredictability of the method because the flat and steep meridians are usually not orthogonal after penetrating keratoplasty,with asymmetric power distribution,all the studies showed an overall reduction of refractive,keratometric or topographic astigmatism,ranging from 30%to 72%with manual or femtosecond-assisted techniques.Most patients with astigmatism higher than 6 diopters had residual cylinder less than or equal to 3 diopters,which can be treated by laser excimer ablation or secondary intraocular lens implantation.展开更多
The use of femtosecond lasers has created an evolution in modern corneal and refractive surgery.With accuracy,safety,and repeatability,eye surgeons can utilize the femtosecond laser in almost all anterior refractive p...The use of femtosecond lasers has created an evolution in modern corneal and refractive surgery.With accuracy,safety,and repeatability,eye surgeons can utilize the femtosecond laser in almost all anterior refractive procedures;laser in situ keratomileusis(LASIK),small incision lenticule extraction(SMILE),penetrating keratoplasty(PKP),insertion of intracorneal ring segments,anterior and posterior lamellar keratoplasty(Deep anterior lamellar keratoplasty(DALK)and Descemet's stripping endothelial keratoplasty(DSEK)),insertion of corneal inlays and cataract surgery.As the technology matures,it will push surgical limits and open new avenues for ophthalmic intervention in areas not yet explored.As we witness the transition from femto-LASIK to femto-cataract surgery it becomes obvious that this innovation is here to stay.This article presents some of the most relevant advances of femtosecond lasers to modern corneal and refractive surgery.展开更多
Keratoconus is a disease characterized by progressive thinning,bulging,and distortion of the cornea.Advanced cases usually present with loss of vision due to high irregular astigmatism.A majority of these cases requir...Keratoconus is a disease characterized by progressive thinning,bulging,and distortion of the cornea.Advanced cases usually present with loss of vision due to high irregular astigmatism.A majority of these cases require surgical intervention.This review provides an update on the current treatment modalities of corneal surgery available for the management of advanced corneal ectasias.展开更多
Several treatment options corresponding to the grade of keratoconus have been established.These are ultra-violet corneal crosslinking and intracorneal ring segments for mild to moderate keratoconus,and penetrating ker...Several treatment options corresponding to the grade of keratoconus have been established.These are ultra-violet corneal crosslinking and intracorneal ring segments for mild to moderate keratoconus,and penetrating keratoplasty or deep anterior lamellar keratoplasty for the more advanced cases of keratoconus.Bowman layer transplantation was developed as a procedure for patients with advanced,progressive keratoconus.The technique consists of transplanting an isolated donor Bowman layer into a mid-stromal pocket of a keratoconic cornea resulting in corneal flattening and stabilization against further ectasia.Thus,it aims at corneal stabilization in eyes with advanced keratoconus,and enabling continued contact lens wear for normal visual functionality.By being a sutureless procedure and using an acellular graft,it potentially avoids commonly known suture and graftrelated complications of penetrating or deep anterior lamellar keratoplasty.The treatment seems to be a promising option in the management of advanced keratoconus in order to postpone or prevent a more invasive corneal surgery,while minimizing the risk of complications and allowing less stringent surveillance and less intensive medical therapy.展开更多
This case report aims at investigating whether two consecutive surgical settings would be beneficial in achieving postoperative success for the patient with blast eye injury. A 45-year-old male patient admitted on 17t...This case report aims at investigating whether two consecutive surgical settings would be beneficial in achieving postoperative success for the patient with blast eye injury. A 45-year-old male patient admitted on 17th October 2011 with history of blast eye injury. Right eye examination revealed central corneal laceration with incarceration of lens matter, multiple foreign bodies also seen embedded in the eyelid margins and in the left cornea. Computed ocular tomography showed a retained intraocular foreign body (IOFB) in the right eye. Simultaneous corneal laceration repair and extraction of the ruptured lens performed as primary procedure under general anesthesia. Intraoperative posterior capsule loss was noticed with vitreous presentation. Anterior vitrectomy with removal of the IOFB was done. Foreign bodies were also removed from the left cornea. Penetrating keratoplasty (PK) with scleral fixated intraocular lens implantation executed 4 months later as secondary procedure. Visual acuity maintained at 6/24 in 2 years follow-up. In conclusion, two consecutive surgical settings has the advantage of calculating the intra ocular lens power.展开更多
文摘AIM:To compare visual,surgical and topographic outcomes of deep anterior lamellar keratoplasty(DALK)and penetrating keratoplasty(PK)for keratoconus(KC).METHODS:In this multicenter,prospective,randomized clinical trial 76 eyes of 71 KC patients operated between January 2011 and July 2014 in 2 tertiary referral hospitals were included. Consecutive patients were alternately selected to receive one of the two surgical methods. Thirty eight eyes underwent DALK with the big-bubble technique and 38 eyes underwent PK.RESULTS:Mean best spectacle corrected visual acuity(BSCVA)at the first postoperative week(P=0.012)and the first postoperative month(P<0.001)was statistically significantly higher in DALK group. The mean BSCVA at12 mo was not significantly different for DALK(0.30±1.99 log MAR)versus PK(0.40±0.33 log MAR)(P=0.104). The76.3% of the eyes had a BSCVA over 0.5 in DALK and 47.4%in PK group(P=0.009). The 7.9% of the eyes had a BSCVA of 1.0 in DALK and 5.3% in PK group(P=0.644). Mean spherical equivalent was-2.94 D in DALK and-3.09 D in PK group.Mean topographic astigmatism was 4.62 D and 4.18 D respectively. Regular topographic patterns were observed in 31(81.6%)of DALK and 29(76.3%)of PK(P=0.574). The most frequent topographic pattern was oblate asymmetric bow tie,seen in 39.5% in DALK and 23.7% in PK. CONCLUSION:Big bubble DALK provides an earlier visual improvement compare to PK. However,visual and topographic outcomes are similar to those in PK at 1y. Postoperative complications including rejection and intraocular pressure elevation are more frequent in PK. DALK is a safer alternative to PK for KC. However,intraoperativeperforation of the Descemet's membrane is a significant complication.
文摘AIM:To analyze the changing trends in penetrating keratoplasty(PKP)indications.METHODS:This retrospective study included all patients with PKP between 2006 and 2017.Patients were classified using histological diagnoses.Our groups were as the following:pseudophakic or aphakic bullous keratopathy,regraft,acute necrotizing and ulcerative keratitis,keratoconus,Fuchs'dystrophy,corneal dystrophy other than Fuchs',corneal scar,other diagnoses and failed endothelial keratoplasty graft.Additionally,two different time-periods(2006-2012 and 2013-2017)were analysed.RESULTS:Totally 1721 histological analyses of 1214 patients were available for review.The diagnoses were pseudophakic or aphakic bullous keratopathy in 487(28.3%),regraft in 443(25.7%),acute necrotizing and ulcerative keratitis in 313(18.2%),corneal scar in 153(8.9%),keratoconus in 140(8.1%).Fuchs'dystrophy in 61(3.5%),corneal dystrophy other than Fuchs'in 46(2.7%),other diagnoses in 44(2.6%)and failed endothelial keratoplasty graft in 34(2.0%)cases.From the first to the second analysed time-period,incidence of acute necrotizing and ulcerative keratitis,corneal scar,Fuchs'dystrophy increased(P<0.032 for all)and incidence of keratoconus significantly decreased(P=0.015).CONCLUSION:Pseudophakic or aphakic bullous keratopathy is the leading indication for PKP,followed by regraft and acute necrotizing and ulcerative keratitis.
基金Supported by the National Natural Science Foundation of China (No.81500703)the Natural Science Foundation of Shandong Province (No.ZR2015YL027)the Innovation Project of Shandong Academy of Medica Sciences
文摘AIM: To review the indications of penetrating keratoplasty(PK) and anterior lamellar keratoplasty(ALK) at Qingdao Eye Hospital, Shandong Eye Institute, Qingdao, China, from 2010 to 2017. METHODS: The data of all patients undergoing PK or ALK from January 2010 to December 2017 was retrospectively reviewed, with the indications during 2010-2013 and 2014-2017 compared. RESULTS: A total of 1869 eyes were included, among which 1405 eyes(75.2%) had PK and 464 eyes(24.8%) had ALK. The leading indications were suppurative keratitis(36.8%), keratoconus(15.5%), herpes keratitis(13.1%), and regraft(10.5%). In eyes undergoing PK, the top four indications were suppurative keratitis(38.7%), herpes keratitis(15.3%), keratoconus(12.6%), and regraft(12.5%) during 2014-2017, with the proportion of suppurative keratitis and herpes keratitis decreased while regraft and keratoconus increased compared with 2010-2013. In eyes with ALK, suppurative keratitis(30.8%), keratoconus(24.1%), corneal dystrophies and degenerations(10.6%), and corneal dermoid tumor(9.7%) were the top four indications, and there was no significant difference for the proportion of each indication between 2010-2013 and 2014-2017. CONCLUSION: Suppurative keratitis is the most common indication for PK and ALK at Qingdao Eye Hospital during 2010-2017, followed by keratoconus, herpes keratitis, and regraft. In eyes treated with PK, the proportion of suppurative keratitis and herpes keratitis decrease while regraft and keratoconus increase during 2014-2017 compared with 2010-2013.
文摘Dear Editor,I am Dr.Jo?o Beato,from the Ophthalmology Department of Sao Jo?o Hospital Center,Porto,Portugal.I write to present a case of combined penetrating keratoplasty(PKP)with temporary Eckardt keratoprosthesis,pars plana vitrectomy(PPV)and Ahmed glaucoma valve(AGV)implantation into the ciliary sulcus in a patient with previous history of
文摘AIM:To evaluate the midterm outcomes of penetrating keratoplasty(PK)following allogeneic cultivated limbal epithelial transplantation(CLET)for bilateral total limbal stem cell deficiency(LSCD).METHODS:Ten patients(10 eyes)with bilateral LSCD were enrolled in this prospective noncomparative case series study.Each participant underwent PK approximately 6 mo after a CLET.Topical tacrolimus,topical and systemic steroids,and oral ciclosporin were administered postoperatively.Best-corrected visual acuity(BCVA),intraocular pressure(IOP),ocular surface grading scores(OSS),corneal graft epithelial rehabilitation,persistent epithelial defect(PED),immunological rejection,and graft survival rate were assessed.RESULTS:The time interval between PK and allogeneic CLET was 6.90±1.29(6-10)mo.BCVA improved from 2.46±0.32 log MAR preoperatively to 0.77±0.55 log MAR post-PK(P<0.001).Kaplan-Meier analysis of mean graft survival revealed graft survival rates of 100%at 12 and 24 mo and 80.0%at 36 mo.PEDs appeared in 5 eyes at different periods post-PK,and graft rejection occurred in 4 eyes.The total OSS decreased from 12.4±4.4 before allogeneic CLET to 1.4±1.51 after PK.CONCLUSION:A sequential therapy design of PK following allogeneic CLET can maintain a stable ocular surface with improved BCVA despite the relatively high graft rejection rate.
文摘AIM:To evaluate the graft rejection and visual outcomes after penetrating keratoplasty(PK)in the presence of various congenital corneal opacities in children.METHODS:In this retrospective cohort study,children who underwent PK were then followed for 5 y.The patient’s medical records were collected from June 2014 until June 2019 and analyzed in December 2019.All patients were children under three years old with congenital corneal opacities with or without microcornea who came to a pediatric ophthalmologist and underwent PK in Jakarta Eye Center(JEC).Beforehand,all children have participated in a thorough evaluation for PK.In the case of severe microcornea was not advised to undergo surgery.The visual outcomes and graft survival rate were described in percentages.The graft survival plot was presented with Kaplan-Meier,while the visual acuity was analyzed using the Wilcoxon signed ranks test.RESULTS:Sixteen eyes from eleven patients(seven girls and four boys)underwent PK.The graft survival rate of the first 6,12,and 18 mo later of keratoplasty was 100%,83.3%,and 66.7%,respectively.The overall mean survival time is 22 mo(standard error 2.419),and no significant difference between the patients underwent PK before and after 36 mo of their age(P=0.52).The graft failure was 50%,and postsurgery complications included cataract 43.7%,band keratopathy 12.5%,and scleromalasia 6.25%.Wilcoxon test analysis of visual acuity post keratoplasty was not statistically significant(P=0.34),while overall showed 44%improvements of visual outcome for 5 y of follow-up.With a good survival at one year up to 22 mo(83.3%),the visual acuity could be achieved(63%),and showed improvements(44%)during follow-up.CONCLUSION:The complications are frequent for pediatric PK.Thus,corneal surgery on infants requires careful case selection,adequate pre-operative evaluation,skilled surgery(optical correction),very close cooperation family–physician,intensive post-operation care,and amblyopia management in the future.
基金Supported by The Ophthalmic Research Center,Shahid Beheshti University of Medical Sciences,Tehran,Iran
文摘Deep anterior lamellar keratoplasty(DALK) has recently been introduced as an alternative procedure to penetrating keratoplasty(PK) for corneal pathologies not affecting the corneal endothelium. DALK does not rely on donor endothelium and requires less rigid criteria for donor corneal tissue quality. Therefore, DALK makes it possible to use donor corneas deemed unsuitable for PK. Furthermore, lamellar keratoplasty allows acellular corneal tissue to be transplanted. As a result, long-term preservation techniques are being revisited to increase the availability of donor corneas and subsequently alleviate constraints of availability, cost, storage, and transportation in many countries. The recent alterations in corneal transplantation techniques and hence the type of donor cornea tissues used for each technique, may require corneal surgeons and eye banks to reevaluate their selection criteria. The purpose of this systematic review is to present an updated analysis on the type and quality of donor corneas used for PK and DALK, assess the influence of donor and eye bank factors on the quality of donor corneas, and determine whether any of these donor factors affect clinical outcomes, complications, and graft survivals.
文摘Background: Keratoglobus is a rare noninflammatory corneal disorder characterized by diffuse corneal thinning and globular protrusion of the cornea. Surgical management of keratoglobus is challenging and the standard method has not yet been defined. Aim: To present the role of large penetrating keratoplasty (PK) in the management of keratoglobus. Case Presentation: A 29-year-old male patient with bilateral keratoglobus presented with acute corneal hydrops in his right eye following extensive Descemet’s membrane rupture, with a visual acuity in this eye limited to hand movement. Peripheral cornea was extremely thin and blue sclera was present. Acute hydrops was managed conservatively at this stage and two months later large PK was performed in the right eye using 9.5 mm diameter graft over a 9 mm patient’s cornea trephination. Minor aqueous leakage was seen on the first postoperative day, managed with 2 more interrupted 10.0 nylon sutures. No further complications were noticed and postoperative course was uneventful. Fifteen months postoperatively the graft was clear and best corrected visual acuity was 20/60. Conclusions: Large penetrating keratoplasty has an important role in the management of keratoglobus, in cases where peripheral tuck-in lamellar keratoplasty or epikeratoplasty present serious intraoperative difficulties in host lamellar dissection and in stabilizing the graft due to extensive peripheral corneal and scleral thinning.
文摘This paper shows how a public eye and research hospital in Turkey initiated Six Sigma principles to reduce the number of complications occurring after penetrating keratoplasty surgeries. Data were collected for nine years. To analyse the complications among 55 patients (59 eyes) underwent penetrative keratoplasty, main tools of Six Sigma’s Define-Measure-Analyze-Improve-Control (DMAIC) improvement cycle such as SIPOC table and Failure, Mode and Effect Analysis (FMEA) were implemented. Sources and root causes of eleven types of complications were identified and reported. For a successful penetrating keratoplasty surgery patient’s anatomy, suitability of donor cornea, experience of ophthalmic surgeon, sterilization and hygiene, and performance of the equipment were determined to be the “critical-to-quality” factors. The complication with the highest hazard score was found to be the glaucoma. The process sigma level of the process was measured to be 3.1418. The surgical team concluded that all types of post-operative complications should be significantly reduced by taking the necessary preventive measures.
基金Project (No. 2011C13029-2) supported by the Major Program for Science and Technology Research of Zhejiang Province, China
文摘Objective: To compare postoperative outcomes of full-bed deep anterior lamellar keratoplasty (DALK) with penetrating keratoplasty (PK) in treating keratoconus. Methods: Seventy-five eyes of 64 patients who received full-bed DALK and 52 eyes of 51 patients who received PK between June 2000 and August 2010 were included in this retrospective study. Full-bed DALK was performed using Yao's hooking-detaching technique. PK was performed using a standard technique. Intraoperative and postoperative complications, visual acuity, rejection, graft survival, endothelial cell density, corneal sensation recovery, and re-innervation were compared between the two groups. Results: A best correct visual acuity of 0.5 or better was achieved in 90.7% of eyes after full-bed DALK and in 92.3% of eyes after PK (P=0.75). By the fifth postoperative year, graft endothelial cell loss reached 34.6% in the PK group vs. 13.9% in the full-bed DALK group (P<0.001). There were no statistical differences in corneal sensitivity recovery or corneal re-innervation between the groups (P>0.05). Intraoperative microperforation occurred in seven out of 75 (9.3%) eyes with a temporally postoperative double anterior chamber in two eyes in the full-bed DALK group. Postoperative complications in the PK vs. the full-bed DALK groups respectively were: rejection (7.7% vs. 0%, P=0.015), high intraocular pressure (IOP) (46.2% vs. 1.3%, P<0.001), secondary glaucoma (9.6% vs. 0%, P=0.006), complicated cataract (19.2% vs. 0%, P<0.001), and wound dehiscence (9.6% vs. 0%, P=0.006). Conclusions: Both full-bed DALK and PK can offer long-term satisfactory visual outcomes for keratoconus. Graft rejection, secondary glaucoma, complicated cataracts, and constant endothelial cell loss were observed in eyes only after PK.
文摘Background:To report a surgical method for treating corneal oedema in a case of late-onset Descemet membrane detachment after penetrating keratoplasty.Case presentation:A 55-year old patient presented with sudden visual loss in his left eye 28 years after penetrating keratoplasty for keratoconus.Slit-lamp biomicroscopy revealed a distortion of the corneal graft anatomy with protrusion of the graft and peripheral thinning and steepening in the residual host tissue,accompanied by corneal graft oedema.Anterior segment optical coherence tomography revealed detachment of Descemet membrane localized to the area of the graft oedema.We proceeded with a full-thickness,partially circumferential incision in the graft-host junction,followed by repositioning and re-suturing of the graft in place,and intracameral air injection in order to achieve reattachment of Descemet membrane.Conclusions:Corneal graft repositioning in combination with re-bubbling may represent an effective therapeutic option in keratoconic patients with peripheral thinning in the residual host corneal tissue and subsequent Descemet membrane detachment.
文摘AIM:To report the outcomes of three cases of corneal perforation managed with simultaneous tectonic Descemet stripping endothelial keratoplasty(t-DSEK)and tectonic Bowman layer transplant(t-BLT)as an alternative to tectonic penetrating keratoplasty(t-PKP).METHODS:Three eyes of three patients receiving simultaneous t-DSEK and t-BLT for corneal perforation were included.The technique for DSEK was modified depending on individual requirements.The t-BLT technique was standardised using an 8 mm graft and fixated with a running suture.Success was measured by the ability of this procedure to close a corneal perforation.RESULTS:All three cases achieved tectonic eye globe restoration and remained stable during the minimum 3-month observation period.Reinterventions were relatively common:2 cases required amniotic membrane transplant for persistent epithelial defects.One case required DSEK rebubbling.One case developed angle closure glaucoma requiring surgical peripheral iridectomy.CONCLUSION:Simultaneous t-DSEK and t-BLT may be a useful strategy for the management of corneal perforation as an alternative management to t-PKP for selected cases.
文摘AIM: To report the fungal organisms, clinical features,surgical treatment strategies, and outcomes of patients with culture-proven exogenous fungal endophthalmitis(EFE) secondary to keratitis, and evaluate the role of surgery in the treatment.METHODS: The clinical records of 27 patients(27 eyes)with culture-proven EFE resulting from fungal keratitis treated at Shandong Eye Institute from January 2007 to January 2015 were retrospectively reviewed. Information about fungal culture results, clinical features, surgical procedures, and final visual acuity was obtained.RESULTS: There were 39 positive culture results from samples of cornea, hypopyon, vitreous and lens capsule,accounting for 56%, 26%, 15% and 2.5%, respectively.Fusarium was identified in 44%(12/27) of the eyes,followed by Aspergillus in 22%(6/27). Posterior segment infection was involved in 78%(21/27) of the patients. The corneal infection was larger than 3 mm×3 mm in 89%(24/27) of the patients, and 22%(6/27) of them had the entire cornea, and even the sclera involved. Three eyes had silicone oil tamponade, and two eyes had retinal detachment. Twenty-two eyes(81.5%) underwent penetrating keratoplasty(PKP), and over half of them(54.5%)were operated within 3d from the onset of antifungal therapy. Fourteen eyes(52%) underwent intracameral antifungal drug injection, and three of them required repeated injections. Fifteen eyes(55.6%) underwent pars plana vitrectomy(PPV). The rate of the eyes undergoing PPV as the initial surgical procedure was 60%(9/15),lower than 77% in PKP. Intravitreal injection was given in 59% of the eyes(16/27), and 75% of them required repeated injections. The final visual acuity was 20/100 or better in 37% of the eyes, and better than counting fingers in 55.6% of the eyes. Five eyes(18.5%) were eviscerated. In the two eyes with concurrent retinal detachment, one achieved retinal reattachment, and the other was eviscerated. In the three eyes with silicone oil tamponade, two eyes received silicone oil removal, and the other one was eviscerated. CONCLUSION: Fusarium and Aspergillus are the dominant pathogens in EFE resulting from keratitis.Aggressive antifungal surgeries including multiple intravitreal injections, PKP and core vitrectomy(especially in the initial surgery) are helpful procedures to improve prognosis of severe EFE secondary to keratitis.
基金supported by the Shandong Provincial Natural Science Foundation(ZR2020QH140)the National Natural Science Foundation of China(82101091)+1 种基金the Academic Promotion Program of Shandong First Medical University(2019ZL001,2019RC008)the Shandong Provincial Key Research and Development Program(2021ZDSYS14)。
文摘Macular corneal dystrophy(MCD)is a progressive,bilateral stromal dystrophic disease that arises from mutations in carbohydrate sulfotransferase 6(CHST6).Corneal transplantation is the ultimate therapeutic solution for MCD patients.Unfortunately,postoperative recurrence remains a significant challenge.We conducted a retrospective review of a clinical cohort comprising 102 MCD patients with 124 eyes that underwent either penetrating keratoplasty(PKP)or deep anterior lamellar keratoplasty(DALK).Our results revealed that the recurrence rate was nearly three times higher in the DALK group(39.13%,9/23 eyes)compared with the PKP group(10.89%,11/101 eyes),suggesting that surgical replacement of the corneal endothelium for treating MCD is advisable to prevent postoperative recurrence.Our experimental data confirmed the robust m RNA and protein expression of CHST6 in human corneal endothelium and the rodent homolog CHST5 in mouse endothelium.Selective knockdown of wild-type Chst5 in mouse corneal endothelium(AC^(siChst5)),but not in the corneal stroma,induced experimental MCD with similar extracellular matrix synthesis impairments and corneal thinning as observed in MCD patients.Mice carrying Chst5 point mutation also recapitulated clinical phenotypes of MCD,along with corneal endothelial abnormalities.Intracameral injection of wild-type Chst5 rescued the corneal impairments in AC^(siChst5)mice and retarded the disease progression in Chst5 mutant mice.Overall,our study provides new mechanistic insights and therapeutic approaches for MCD treatment by highlighting the role of corneal endothelium in MCD development.
文摘Postoperative visual acuity can be limited by post-keratoplasty astigmatism,even with a clear corneal graft.Astigmatism management can be performed by selective suture removal,adjustment of sutures,optical correction,photorefractive procedures,wedge resection,intra-ocular lens implantation,intracorneal ring segments,relaxing incisions with or without compression sutures and repeated keratoplasty.Relaxing incisions can be made in the graft,graft-host interface or host cornea.Despite the unpredictability of the method because the flat and steep meridians are usually not orthogonal after penetrating keratoplasty,with asymmetric power distribution,all the studies showed an overall reduction of refractive,keratometric or topographic astigmatism,ranging from 30%to 72%with manual or femtosecond-assisted techniques.Most patients with astigmatism higher than 6 diopters had residual cylinder less than or equal to 3 diopters,which can be treated by laser excimer ablation or secondary intraocular lens implantation.
文摘The use of femtosecond lasers has created an evolution in modern corneal and refractive surgery.With accuracy,safety,and repeatability,eye surgeons can utilize the femtosecond laser in almost all anterior refractive procedures;laser in situ keratomileusis(LASIK),small incision lenticule extraction(SMILE),penetrating keratoplasty(PKP),insertion of intracorneal ring segments,anterior and posterior lamellar keratoplasty(Deep anterior lamellar keratoplasty(DALK)and Descemet's stripping endothelial keratoplasty(DSEK)),insertion of corneal inlays and cataract surgery.As the technology matures,it will push surgical limits and open new avenues for ophthalmic intervention in areas not yet explored.As we witness the transition from femto-LASIK to femto-cataract surgery it becomes obvious that this innovation is here to stay.This article presents some of the most relevant advances of femtosecond lasers to modern corneal and refractive surgery.
文摘Keratoconus is a disease characterized by progressive thinning,bulging,and distortion of the cornea.Advanced cases usually present with loss of vision due to high irregular astigmatism.A majority of these cases require surgical intervention.This review provides an update on the current treatment modalities of corneal surgery available for the management of advanced corneal ectasias.
文摘Several treatment options corresponding to the grade of keratoconus have been established.These are ultra-violet corneal crosslinking and intracorneal ring segments for mild to moderate keratoconus,and penetrating keratoplasty or deep anterior lamellar keratoplasty for the more advanced cases of keratoconus.Bowman layer transplantation was developed as a procedure for patients with advanced,progressive keratoconus.The technique consists of transplanting an isolated donor Bowman layer into a mid-stromal pocket of a keratoconic cornea resulting in corneal flattening and stabilization against further ectasia.Thus,it aims at corneal stabilization in eyes with advanced keratoconus,and enabling continued contact lens wear for normal visual functionality.By being a sutureless procedure and using an acellular graft,it potentially avoids commonly known suture and graftrelated complications of penetrating or deep anterior lamellar keratoplasty.The treatment seems to be a promising option in the management of advanced keratoconus in order to postpone or prevent a more invasive corneal surgery,while minimizing the risk of complications and allowing less stringent surveillance and less intensive medical therapy.
文摘This case report aims at investigating whether two consecutive surgical settings would be beneficial in achieving postoperative success for the patient with blast eye injury. A 45-year-old male patient admitted on 17th October 2011 with history of blast eye injury. Right eye examination revealed central corneal laceration with incarceration of lens matter, multiple foreign bodies also seen embedded in the eyelid margins and in the left cornea. Computed ocular tomography showed a retained intraocular foreign body (IOFB) in the right eye. Simultaneous corneal laceration repair and extraction of the ruptured lens performed as primary procedure under general anesthesia. Intraoperative posterior capsule loss was noticed with vitreous presentation. Anterior vitrectomy with removal of the IOFB was done. Foreign bodies were also removed from the left cornea. Penetrating keratoplasty (PK) with scleral fixated intraocular lens implantation executed 4 months later as secondary procedure. Visual acuity maintained at 6/24 in 2 years follow-up. In conclusion, two consecutive surgical settings has the advantage of calculating the intra ocular lens power.
