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Rickmann A, Wahl S, Messias A, Trouvain AM, Roberts PK, Boden KT, Szurman P. Clinical Outcome of Endothelium-Outward Preloaded Descemet Membrane Endothelial Keratoplasty in Long-Term Dextran-Containing Transport Medium Preservation. Cornea 2025:00003226-990000000-00799. [PMID: 39836527 DOI: 10.1097/ico.0000000000003817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2024] [Accepted: 12/20/2024] [Indexed: 01/23/2025]
Abstract
PURPOSE To analyze the clinical outcome of organ-cultured endothelium-outward preloaded DMEK (pDMEK) using the RAPID cartridge. METHODS This prospective study included 80 eyes of 80 patients who received a pDMEK. Best-corrected visual acuity (BCVA), endothelial cell count (ECC), and central corneal thickness were measured preoperatively and 4 to 6 weeks, 3 months, 6 months, and 1 year postoperatively. The difficulty of graft preparation and implantation, rebubbling, and re-DMEK frequency were evaluated. RESULTS The graft preparation time was 5.3 ± 1.2 minutes on average. After preparation, the ECC before preloading was 2652 ± 180 cells/mm2 (P = 0.9, endothelial cell loss [ECL] = 0.8%). After pDMEK, the cornea started to clear up after 1.6 ± 1 day. Compared with the preoperative values, BCVA and central corneal thickness significantly improved during the postoperative course (P < 0.0001). At the first follow-up examination, the ECL was 43% (P < 0.0001) and remained stable throughout the follow-up period (all P > 0.5). Rebubbling was necessary in 39/80 patients (48.75%). One patient (1/80, 1.25%) required a re-DMEK after 1 year owing to secondary graft failure with insufficient ECC. CONCLUSIONS The clinical results after endothelium-outward pDMEK showed a significant improvement in BCVA and corneal thickness over the 1-year follow-up period, but the relatively high rebubbling rate and ECL should be taken into account. Therefore, we recommend that further comparative clinical studies should be conducted.
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Affiliation(s)
- Annekatrin Rickmann
- Eye Clinic Sulzbach, Knappschaft Hospital Saar, Sulzbach/Saar, Germany
- University Eye Hospital, University of Tübingen, Tübingen, Germany
| | - Silke Wahl
- Eye Clinic Sulzbach, Knappschaft Hospital Saar, Sulzbach/Saar, Germany
| | - André Messias
- Eye Clinic Sulzbach, Knappschaft Hospital Saar, Sulzbach/Saar, Germany
- Department of Ophthalmology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil; and
| | - André M Trouvain
- Eye Clinic Sulzbach, Knappschaft Hospital Saar, Sulzbach/Saar, Germany
| | - Philipp K Roberts
- Eye Clinic Sulzbach, Knappschaft Hospital Saar, Sulzbach/Saar, Germany
| | - Karl T Boden
- Eye Clinic Sulzbach, Knappschaft Hospital Saar, Sulzbach/Saar, Germany
| | - Peter Szurman
- Eye Clinic Sulzbach, Knappschaft Hospital Saar, Sulzbach/Saar, Germany
- Klaus Heimann Eye Research Institute (KHERI), Knappschaft Hospital Saar, Sulzbach, Germany
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Trouvain AM, Szurman P, Wahl S, Siegel R, Boden KT, Seitz B, Fries FN, Rickmann A. Impact of Previous Cataract Surgery in Corneal Donors on the Outcome of Descemet Membrane Endothelial Keratoplasty. Cornea 2024; 43:844-852. [PMID: 39377776 DOI: 10.1097/ico.0000000000003423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 10/02/2023] [Indexed: 10/09/2024]
Abstract
PURPOSE The aim of this study was to investigate differences between phakic, pseudophakic, and scarred stromal donor tissue for their influence on complication rates during preparation or implantation and on the postoperative outcome of Descemet membrane endothelial keratoplasty (DMEK). METHODS We retrospectively compared 484 eyes undergoing DMEK, divided into 3 subgroups of donor tissue (1: phakic, 2: pseudophakic, and 3: scarred stromal). Visual acuity, central corneal thickness (CCT), and endothelial cell count were monitored preoperatively and postoperatively at 6 weeks and 3, 6, 12, and 24 months. The incidence of intraoperative and postoperative complications was analyzed. RESULTS The risk of adherence and tearing during preparation was significantly higher in group 2 than in the other groups (p's < 0.001). No significant difference was found for visual acuity (p's ≥ 0.368) and long-term CCT, but CCT recovery took longer in group 2 (P = 0.003), normalizing after 3 months (p's ≥ 0.096). The overall mean endothelial cell count was lower in group 2 compared with the other groups (P = 0.011). No difference in the rebubbling rate was detected (P = 0.890). However, the risk of repeat keratoplasty for phakic grafts was lower compared with group 2 (P = 0.008). CONCLUSIONS Pseudophakic donor grafts are more difficult to prepare and implant, resulting in longer recovery times and a higher risk of graft failure. However, when the preparation is uneventful and no graft failure occurs, pseudophakic grafts show a comparable outcome. Given the shortage of corneal donors and the high prevalence of pseudophakic corneal donors, they should not generally be excluded from corneal donation for DMEK.
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Affiliation(s)
- André M Trouvain
- Eye Clinic Sulzbach, Knappschaft Hospital Saar, Sulzbach/Saar, Germany
| | - Peter Szurman
- Eye Clinic Sulzbach, Knappschaft Hospital Saar, Sulzbach/Saar, Germany
| | - Silke Wahl
- Eye Clinic Sulzbach, Knappschaft Hospital Saar, Sulzbach/Saar, Germany
| | - Rudolf Siegel
- Industrial and Organizational Psychology, Saarland University, Saarbruecken, Germany; and
| | - Karl Thomas Boden
- Eye Clinic Sulzbach, Knappschaft Hospital Saar, Sulzbach/Saar, Germany
| | - Berthold Seitz
- Department of Ophthalmology, Saarland University Medical Center (UKS), Homburg/Saar, Germany
| | - Fabian N Fries
- Department of Ophthalmology, Saarland University Medical Center (UKS), Homburg/Saar, Germany
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Rocha de Lossada C, Airaldi M, Semeraro F, Romano V. DMEK F-marking complication: case report and literature review. CANADIAN JOURNAL OF OPHTHALMOLOGY 2023; 58:e207-e209. [PMID: 37040868 DOI: 10.1016/j.jcjo.2023.03.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 03/19/2023] [Indexed: 04/13/2023]
Affiliation(s)
- Carlos Rocha de Lossada
- Qvision, Vithas Almería Hospital, Almería, Spain; Vithas Málaga Hospital, Málaga, Spain; University of Málaga Regional Hospital, Málaga, Spain; University of Seville, Seville, Spain
| | | | | | - Vito Romano
- University of Brescia, Brescia, Italy; Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom
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Kingsbury KD, Skeie JM, Cosert K, Schmidt GA, Aldrich BT, Sales CS, Weller J, Kruse F, Thomasy SM, Schlötzer-Schrehardt U, Greiner MA. Type II Diabetes Mellitus Causes Extracellular Matrix Alterations in the Posterior Cornea That Increase Graft Thickness and Rigidity. Invest Ophthalmol Vis Sci 2023; 64:26. [PMID: 37326594 DOI: 10.1167/iovs.64.7.26] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023] Open
Abstract
Purpose There is a pressing need to investigate the impact of type II diabetes mellitus on the posterior cornea in donor tissues given its increasing prevalence and potential impact on endothelial keratoplasty surgical outcomes. Methods Immortalized human cultured corneal endothelial cells (CECs; HCEC-B4G12) were grown in hyperglycemic media for 2 weeks. Extracellular matrix (ECM) adhesive glycoprotein expression and advanced glycation end products (AGEs) in cultured cells and corneoscleral donor tissues, as well as the elastic modulus for the Descemet membrane (DMs) and CECs of diabetic and nondiabetic donor corneas, were measured. Results In CEC cultures, increasing hyperglycemia resulted in increased transforming growth factor beta-induced (TGFBI) protein expression and colocalization with AGEs in the ECM. In donor corneas, the thicknesses of the DM and the interfacial matrix (IFM) between the DM and stroma both increased from 8.42 ± 1.35 µm and 0.504 ± 0.13 µm in normal corneas, respectively, to 11.13 ± 2.91 µm (DM) and 0.681 ± 0.24 µm (IFM) in non-advanced diabetes (P = 0.013 and P = 0.075, respectively) and 11.31 ± 1.76 µm (DM) and 0.744 ± 0.18 µm (IFM) in advanced diabetes (AD; P = 0.0002 and P = 0.003, respectively). Immunofluorescence in AD tissues versus controls showed increased AGEs (P < 0.001) and markedly increased labeling intensity for adhesive glycoproteins, including TGFBI, that colocalized with AGEs. The elastic modulus significantly increased between AD and control tissues for the DMs (P < 0.0001) and CECs (P < 0.0001). Conclusions Diabetes and hyperglycemia alter human CEC ECM structure and composition, likely contributing to previously documented complications of endothelial keratoplasty using diabetic donor tissue, including tearing during graft preparation and reduced graft survival. AGE accumulation in the DM and IFM may be a useful biomarker for determining diabetic impact on posterior corneal tissue.
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Affiliation(s)
- Kenten D Kingsbury
- Department of Ophthalmology and Visual Sciences, Carver College of Medicine, University of Iowa, Iowa City, Iowa, United States
- Iowa Lions Eye Bank, Coralville, Iowa, United States
| | - Jessica M Skeie
- Department of Ophthalmology and Visual Sciences, Carver College of Medicine, University of Iowa, Iowa City, Iowa, United States
- Iowa Lions Eye Bank, Coralville, Iowa, United States
| | - Krista Cosert
- Department of Surgical & Radiological Sciences, School of Veterinary Medicine, University of California, Davis, Davis, California, United States
- Department of Ophthalmology & Vision Science, School of Medicine, University of California, Davis, Davis, California, United States
| | | | - Benjamin T Aldrich
- Department of Ophthalmology and Visual Sciences, Carver College of Medicine, University of Iowa, Iowa City, Iowa, United States
- Iowa Lions Eye Bank, Coralville, Iowa, United States
| | - Christopher S Sales
- Department of Ophthalmology and Visual Sciences, Carver College of Medicine, University of Iowa, Iowa City, Iowa, United States
- Iowa Lions Eye Bank, Coralville, Iowa, United States
| | - Julia Weller
- Department of Ophthalmology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Friedrich Kruse
- Department of Ophthalmology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Sara M Thomasy
- Department of Surgical & Radiological Sciences, School of Veterinary Medicine, University of California, Davis, Davis, California, United States
- Department of Ophthalmology & Vision Science, School of Medicine, University of California, Davis, Davis, California, United States
| | | | - Mark A Greiner
- Department of Ophthalmology and Visual Sciences, Carver College of Medicine, University of Iowa, Iowa City, Iowa, United States
- Iowa Lions Eye Bank, Coralville, Iowa, United States
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Bandeira F, Grottone GT, Covre JL, Cristovam PC, Loureiro RR, Pinheiro FI, Casaroli-Marano RP, Donato W, Gomes JÁP. A Framework for Human Corneal Endothelial Cell Culture and Preliminary Wound Model Experiments with a New Cell Tracking Approach. Int J Mol Sci 2023; 24:ijms24032982. [PMID: 36769303 PMCID: PMC9917640 DOI: 10.3390/ijms24032982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 01/21/2023] [Accepted: 01/30/2023] [Indexed: 02/05/2023] Open
Abstract
Cell injection therapy is emerging as an alternative to treat corneal endothelial dysfunction (CED) and to avoid corneal scarring due to bullous keratopathy. However, establishing a standardized culture procedure that provides appropriate cell yield while retaining functional features remains a challenge. Here, we describe a detailed framework obtained from in vitro culture of human corneal endothelial cells (HCECs) and comparative in vivo experimental models for CED treatment with a new cell tracking approach. Two digestion methods were compared regarding HCEC morphology and adhesion. The effect of Y-27632 (ROCKi) supplementation on final cell yield was also assessed. Cell adhesion efficacy with two cell delivery systems (superparamagnetic embedding and cell suspension) was evaluated in an ex vivo human cornea model and in an in vivo rabbit CED model. The injection of supplemented culture medium or balanced salt solution (BSS) was used for the positive and negative controls, respectively. HCEC isolation with collagenase resulted in better morphology and adhesion of cultured HCEC when compared to EDTA. Y-27632 supplementation resulted in a 2.6-fold increase in final cell yield compared to the control. Ex vivo and in vivo adhesion with both cell delivery systems was confirmed by cell tracker fluorescence detection. Corneal edema and opacity improved in both animal groups treated with cultured HCEC. The corneas in the control groups remained opaque. Both HCEC delivery systems seemed comparable as treatments for CED and for the prevention of corneal scarring.
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Affiliation(s)
- Francisco Bandeira
- Department of Ophthalmology, Federal University of São Paulo, São Paulo 04023-062, Brazil
- Medicine School, Barcelona University, 08007 Barcelona, Spain
- Correspondence: ; Tel.: +55-2197-2355-742
| | | | - Joyce Luciana Covre
- Department of Ophthalmology, Federal University of São Paulo, São Paulo 04023-062, Brazil
| | | | - Renata Ruoco Loureiro
- Department of Ophthalmology, Federal University of São Paulo, São Paulo 04023-062, Brazil
| | - Francisco Irochima Pinheiro
- Biotechnology Post-Graduate Program, Potiguar University, Natal 59082-902, Brazil
- Department of Surgery, Federal University of Rio Grande do Norte, Natal 59078-970, Brazil
| | | | - Waleska Donato
- Department of Ophthalmology, Federal University of São Paulo, São Paulo 04023-062, Brazil
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Solley KD, Berges AJ, Phillips E, Ding AS, Diaz CM, Pramanik S, Yazdi Y, Parikh KS. DescePrep Significantly Increases Descemet Membrane Endothelial Keratoplasty Processing Efficiency and Success Rate in Diabetic Human Donor Corneas in Comparison With Manual Dissection. Cornea 2022; 41:1284-1290. [PMID: 35867682 DOI: 10.1097/ico.0000000000003096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 05/24/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE The purpose of this study was to compare the safety, efficacy, and efficiency of a Descemet membrane endothelial keratoplasty (DMEK) graft processing device, DescePrep, with a manual dissection technique through the measurement of tissue yield, processing time, and graft viability in nondiabetic and diabetic donor corneas. METHODS Nondiabetic (n = 20) and diabetic (n = 20) donor corneas were processed using DescePrep, which standardizes the liquid bubble technique. Nondiabetic (n = 20) and diabetic (n = 24) donor corneas were also processed through manual dissection. Corneas were stained, processed, and then evaluated for processing success rate and time. Randomly selected corneas (n = 5, each) were evaluated for cell viability using live/dead staining. RESULTS One hundred percent of nondiabetic and 95% of diabetic corneas were processed successfully with DescePrep in an average of 3.37 minutes. Ninety percent of nondiabetic and 50% of diabetic corneas were processed successfully with manual dissection in an average of 9.87 minutes. DescePrep had a significantly lower processing time ( P < 0.0001) and significantly higher success rate in comparison with manual dissection. DescePrep grafts had an average cell viability of 91.1% ± 3.3% in nondiabetic and 91.5% ± 2.4% in diabetic corneas. Grafts prepared with manual dissection had an average cell viability of 89.5% ± 5.8% in nondiabetic and 88.1% ± 4.3% in diabetic corneas. CONCLUSIONS DescePrep provides a more effective and efficient method of cornea preparation in comparison with the current standard, particularly in diabetic corneas, while providing comparable cell viability. Thus, DescePrep offers standardized DMEK processing that produces high-quality grafts at high yields, with the potential to expand access and improve the quality of DMEK graft preparation in a larger pool of donors.
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Affiliation(s)
| | | | | | - Andy S Ding
- School of Medicine, Johns Hopkins University, Baltimore, MD
| | | | - Sudeep Pramanik
- Research and Development, Eyedea Medical, Baltimore, MD
- Mid-Atlantic Cornea Consultants, Baltimore, MD
| | - Youseph Yazdi
- Center for Bioengineering Innovation & Design, Johns Hopkins University, Baltimore, MD
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kunal S Parikh
- Research and Development, Eyedea Medical, Baltimore, MD
- Center for Bioengineering Innovation & Design, Johns Hopkins University, Baltimore, MD
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD
- Center for Nanomedicine, Johns Hopkins University School of Medicine, Baltimore, MD; and
- Department of Ophthalmology, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD
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The Cologne-Mecklenburg-Vorpommern DMEK Donor Study (COMEDOS) - design and review of the influence of donor characteristics on Descemet membrane endothelial keratoplasty (DMEK) outcome. Graefes Arch Clin Exp Ophthalmol 2022; 260:2417-2426. [PMID: 35294636 PMCID: PMC9325796 DOI: 10.1007/s00417-022-05594-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 02/04/2022] [Accepted: 02/15/2022] [Indexed: 11/23/2022] Open
Abstract
Background Posterior lamellar keratoplasty and especially Descemet membrane endothelial keratoplasty (DMEK) are gaining interest worldwide. Little is known about the influence of donor factors on DMEK outcome. Here we provide an overview of the existing peer-reviewed literature on this topic and present the design of the upcoming cooperation study COMEDOS (Cologne-Mecklenburg-Vorpommern DMEK Donor Study). Methods A literature search of PubMed and MEDLINE was conducted to retrieve articles published between September 2013 and May 2021. Seventeen peer-reviewed articles were selected. Design and concept of the prospective COMEDOS are outlined. Results Main interest parameters were the donor diabetes mellitus status, age, and lens status. There is a large heterogeneity regarding the sample size, study design, and investigated parameters. There seems to be a consensus that younger donors are associated with tighter rolls, a more difficult preparation, and unfolding setting. Diabetic donors seem to increase the risk of tissue tearing due to adherences and result more frequently in preparation failure. The COMEDOS aims not only to analyze the diabetes status of the donor, but also to correlate all donor systemic comorbidities and their ophthalmologic history to the DMEK clinical outcome. Furthermore, a correlation of Descemet membrane lamella preparation and surgery outcome is planned. Conclusion Currently, there is a lack of knowledge regarding the effect and impact of donor tissue characteristics on DMEK outcome and complications. An in-depth investigation is planned by the upcoming COMEDOS to close this knowledge gap.![]()
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The Last 200 Surgeon-Loaded Descemet Membrane Endothelial Keratoplasty Tissue Versus the First 200 Preloaded Descemet Membrane Endothelial Keratoplasty Tissue. Cornea 2021; 39:1261-1266. [PMID: 32541187 DOI: 10.1097/ico.0000000000002400] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE The purpose of this study was to compare the clinical outcomes from using eye bank-prepared, endothelium-out preloaded Descemet membrane endothelial keratoplasty (DMEK) tissue with those obtained with endothelium-out surgeon-loaded DMEK tissue using the same surgical technique at 1 site. METHODS This study retrospectively reviewed 400 consecutive cases of DMEK from March 2016 to April 2018. The last 200 cases using surgeon-loaded tissue were compared with the first 200 cases using preloaded tissue. Statistical analysis was performed using the Wilcoxon signed-rank test, binomial logistic regression, Kruskal-Wallis 1-way analysis of variance, Student t test, or Pearson χ tests. RESULTS Comparing surgeon-loaded versus preloaded DMEK tissue, respectively, no statistical difference was found in the mean 6-month postoperative values for endothelial cell loss (32.9% ± 18.5% vs. 29.9% ± 16.4%, P = 0.31), best corrected visual acuity (20/26 vs. 20/25, P = 0.54), or change in central corneal thickness (-14.4% ± 8.9% vs. -15.6% ± 11.7%, P = 0.43). The mean 1-year endothelial cell loss was also not significantly different (37.6% ± 17.2% vs. 33.2% ± 14.8%, P = 0.07). Overall, the rebubble rate for surgeon-loaded tissue was 17.5% and 12.5% for preloaded tissue, a statistically nonsignificant difference. Operative outcomes for mean tissue scroll tightness (1-4) and tissue unscroll time (minutes) for surgeon-loaded and preloaded tissue were similar between groups (2.4 vs. 2.2, P = 0.12 and 3.5 vs. 3.3 minutes, P = 0.50). CONCLUSIONS Tissue that is trephinated, stained, and loaded into an injector by the eye bank and then shipped to the surgeon had no difference in clinical outcomes compared with tissue where the surgeon performs these steps. The safety and speed of using preloaded tissue should be considered by DMEK surgeons.
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Luke W, Tamme GH, Yee Chen J, Richard M. Corneal Donor Characteristics and Descemet Membrane Endothelial Keratoplasty Success: A Scoping Review. Cornea 2021; 40:930-935. [PMID: 33591040 DOI: 10.1097/ico.0000000000002682] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 12/28/2020] [Indexed: 11/27/2022]
Abstract
PURPOSE The purpose of this study was to review published data on donor characteristics and the influence on preoperative Descemet membrane endothelial keratoplasty (DMEK) preparation and intraoperative graft manipulation. METHODS A systematic review of PubMed, EMBASE, OVID MEDLINE, and EBSCOhost was conducted up to April 2020. Studies were screened and predefined data criteria extracted. Eleven studies were found to meet the inclusion criteria. RESULTS Research regarding donor characteristics and the relationship to DMEK graft preparation and intraoperative graft manipulation was found to be limited because of the overall low-quality data. However, there was a trend of evidence supporting donor diabetes increasing the risk of graft tearing and consequent preparation failure and younger donors producing tighter scrolls complicating intraoperative graft unfolding. CONCLUSIONS Further research into the area is warranted to better understand how donor characteristics impact preoperative DMEK graft preparation and intraoperative graft manipulation.
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Affiliation(s)
- Weinel Luke
- Department of Surgical and Perioperative Medicine, Ophthalmology, Flinders Medical Centre, Bedford Park, South Australia
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The effects of type 2 diabetes mellitus on the corneal endothelium and central corneal thickness. Sci Rep 2021; 11:8324. [PMID: 33859349 PMCID: PMC8050290 DOI: 10.1038/s41598-021-87896-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 03/30/2021] [Indexed: 12/04/2022] Open
Abstract
Aim of this study is to evaluate the differences in corneal endothelial cell morphology and corneal thickness in patients with and without type 2 diabetes related to age, disease duration, and HbA1c percentage. This retrospective cross-sectional study included 511 (1022 eyes) type 2 diabetes patients and 900 (1799 eyes) non-diabetic patients. The endothelial cell density (ECD), variation in endothelial cell size (CV), percentage of hexagonal cells, and central corneal thickness (CCT) were analyzed using a noncontact specular microscope and a Pentacam Scheimpflug camera. We also examined the correlation between the corneal parameters and the duration of diabetes. For total ages, the subjects with type 2 diabetes showed significantly lower ECD, hexagonality, higher CV, and thicker CCT than the control group. This difference was more pronounced in patients with long-standing DM (≥ 10 years) and high HbA1c (≥ 7%). When stratified by age group, from the 60 s group, corneal endothelial cell parameters showed a statistically significant difference between DM and control groups. The duration of diabetes was inversely correlated with ECD (r = − 0.167; p = 0.000). These findings suggest that diabetes affects corneal endothelial cell in older age and those with long-standing DM and higher HbA1c. Regular corneal endothelial examinations are required in diabetic patients.
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Vertical Scrolling Axis of Corneal Endothelial Grafts for Descemet Membrane Endothelial Keratoplasty. Cornea 2020; 40:497-501. [PMID: 33298743 DOI: 10.1097/ico.0000000000002583] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Heterogeneity in scrolling behavior of Descemet membrane endothelial keratoplasty (DMEK) grafts complicates DMEK surgery. This prospective observational study assessed scrolling axes of DMEK grafts relative to the donor's eye. METHODS The eye bank randomly marked the rim of corneoscleral donor buttons during trephination and recorded the position relative to the donor's axis. Surgeons were masked to the absolute position of the eye bank marking and recorded the scrolling axis relative to the eye bank marking and DMEK upside-down orientation. The scrolling axis was categorized as vertical (0 to 30 degrees and 150 to 180 degrees), oblique (>30 to 60 degrees and 120 to <150 degrees), and horizontal (>60 to <120 degrees). Scrolling patterns of corneas from the same donor were assessed. RESULTS Scrolling patterns of 202 donor corneas from 149 donors were determined. The donor graft scrolled predominantly vertically to the donor's cornea [75%; 95% confidence interval (CI), 68%-80%]. Horizontal axes (11%) and oblique axes (14%) were less common. The median deviation in scrolling axes after unfolding the grafts was 0 degrees from the original scrolling axis (interquartile range, 0-15), indicating that scrolling axes were stable. Fellow eyes of 46 donors had 3.55 times higher odds of a nonvertical scrolling pattern if the first eye had a nonvertical scrolling pattern (95% CI, 1.37-9.20), suggesting that donor factors influencing both eyes could contribute to scrolling patterns. CONCLUSIONS DMEK grafts have a natural and stable scrolling tendency at vertical axis of donor's cornea. Anticipating scrolling axes might help improve preparation techniques for DMEK grafts and outcomes.
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Gruber M, Reinhard T, Wacker K, Maier PC. Scrolling of the Donor Cornea in Dependence of Temperature and Osmolarity for Descemet Membrane Endothelial Keratoplasty. Klin Monbl Augenheilkd 2020; 239:308-312. [PMID: 33202433 DOI: 10.1055/a-1227-4748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND After preparation of a graft for Descemet membrane endothelial keratoplasty (DMEK), the diameter of the graft's scroll varies significantly. In particular, narrow scrolls may complicate DMEK surgery. In this study we investigated how temperature, osmolarity, and deswelling of the donor tissue influence scrolling diameter. MATERIAL AND METHODS In this study we examined donor corneas that could not be used for transplantation. The diameter of the DMEK donor scrolls was measured after graft preparation by reflected light microscopy under different conditions: (1) The diameter of the roll was measured in Ringer's solution at temperatures of 5 °C, 24 °C and 35 °C. (2) To study the effect of different culture conditions we used 6% dextran-containing medium for 10 min, 20 min, 16 h and 24 h, and hyper- and hypoosmolar fluids (5% NaCl or aqua dest) for 5 min each. RESULTS The median donors age was 62 years. The median endothelial cell density of the donor corneas was 1679 cells/mm2. The median diameter of the DMEK scroll was 1.35 mm in Ringer's solution at 24 °C (IQR, 1.04 - 1.89). In Ringer's solution at different temperatures, the scrolling diameter changed between 0.02 mm and 0.29 mm. The change in osmolarity resulted in a difference of 0.02 mm to 0.46 mm. Deswelling with dextran resulted in a change of scrolling diameter between 0.02 mm and 0.09 mm. SUMMARY In this experimental case series, the diameter of the DMEK scroll did not change due to changes of temperature, osmolarity or deswelling. Influencing the graft's scroll to standardize and simplify the DMEK surgery remains an interesting goal for future studies.
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Affiliation(s)
- Markus Gruber
- Klinik für Augenheilkunde, Universitätsklinikum Freiburg
| | | | - Katrin Wacker
- Klinik für Augenheilkunde, Universitätsklinikum Freiburg
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Descemet membrane endothelial keratoplasty (DMEK): clinical results of precut versus surgeon-cut grafts. Graefes Arch Clin Exp Ophthalmol 2020; 259:113-119. [PMID: 32845370 PMCID: PMC7790790 DOI: 10.1007/s00417-020-04901-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 08/10/2020] [Accepted: 08/16/2020] [Indexed: 11/12/2022] Open
Abstract
Purpose This study aims to investigate possible differences in clinical outcomes between precut and surgeon-cut grafts for Descemet membrane endothelial keratoplasty (DMEK). Methods 142 consecutive patients who underwent DMEK were included in the study. 44 patients received precut tissues, and 98 patients received surgeon-cut tissues. Precut grafts were allocated to the patient by the German Society for Tissue Transplantation if available. We compared the outcomes of both groups for changes in visual acuity, central corneal thickness, endothelial cell density, re-bubbling rate, and graft failure rate. Results Patients who received precut tissues experienced similar increase in visual acuity (median change 0.4 logMAR) and decrease of corneal swelling (median change 132 μm) compared with those who received surgeon-cut tissues (median VA change 0.3 logMAR, p = 0.55, CCT change 118 μm, p = 0.63). There was no statistical difference in endothelial cell density (1436 vs. 1569 cells/mm2, p = 0.37), re-bubbling (32% vs. 35%, p = 0.85), and graft failure rate (5% vs. 1%, p = 0.23). No primary graft failure occurred in the group of precut grafts. Conclusion Both methods lead to comparable results for visual acuity, corneal deswelling, endothelial cell density, and re-bubbling rate. A previously described higher graft failure rate for precut tissues could not be confirmed in our study. Thus, we do not see medical reasons against the use of precut tissues. There are several advantages of precut DMEK tissues over surgeon-cut tissues, especially the prevention of graft loss during preparation in the operating theater.
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14
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Tissue engineered ultra-thin descemet stripping corneal endothelial layers using porcine cornea and stem cells. Exp Eye Res 2020; 199:108192. [PMID: 32805263 DOI: 10.1016/j.exer.2020.108192] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 07/25/2020] [Accepted: 08/07/2020] [Indexed: 12/13/2022]
Abstract
Due to their very poor proliferative capacity, the dysfunction of corneal endothelial cells can sometimes lead to incurable eye diseases that require corneal transplantation. Although many studies have been performed to reconstruct corneal endothelial cells, corneal transplantation is still considered to be the established approach. In this study, we developed bio-engineered Descemet stripping endothelial (DSE) layers, using porcine cornea and induced pluripotent stem cell (iPSC)-derived corneal endothelial cells (iCECs). First, we optimized a protocol to prepare an ultra-thin and decellularized Descemet stripping (DS) scaffold from porcine cornea. Our DS layers show over 90% transparency compared to the control. Porcine-derived cells and xenogenic antigens disappeared, whereas the collagen matrix remained in the graft. Next, corneal endothelial cell lines or iCECs were seeded on the decellularized DS graft and cultured for 7 days. The drying method reduced graft rolling and edema, and increased transparency during culture. The reseeded cells were evenly distributed over the graft, and most of the cells survived. Although future clinical studies are warranted, engineered DSE tissues using xenogenic tissues and stem cells will be useful tools for the treatment of incurable corneal diseases.
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Ong HS, Peh G, Neo DJH, Ang HP, Adnan K, Nyein CL, Morales-Wong F, Bhogal M, Kocaba V, Mehta JS. A Novel Approach of Harvesting Viable Single Cells from Donor Corneal Endothelium for Cell-Injection Therapy. Cells 2020; 9:cells9061428. [PMID: 32526886 PMCID: PMC7349718 DOI: 10.3390/cells9061428] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 05/25/2020] [Accepted: 06/02/2020] [Indexed: 12/13/2022] Open
Abstract
Donor corneas with low endothelial cell densities (ECD) are deemed unsuitable for corneal endothelial transplantation. This study evaluated a two-step incubation and dissociation harvesting approach to isolate single corneal endothelial cells (CECs) from donor corneas for corneal endothelial cell-injection (CE-CI) therapy. To isolate CECs directly from donor corneas, optimization studies were performed where donor Descemet’s membrane/corneal endothelium (DM/CE) were peeled and incubated in either M4-F99 or M5-Endo media before enzymatic digestion. Morphometric analyses were performed on the isolated single cells. The functional capacities of these cells, isolated using the optimized simple non-cultured endothelial cells (SNEC) harvesting technique, for CE-CI therapy were investigated using a rabbit bullous keratopathy model. The two control groups were the positive controls, where rabbits received cultured CECs, and the negative controls, where rabbits received no CECs. Whilst it took longer for CECs to dislodge as single cells following donor DM/CE incubation in M5-Endo medium, CECs harvested were morphologically more homogenous and smaller compared to CECs obtained from DM/CE incubated in M4-F99 medium (p < 0.05). M5-Endo medium was hence selected as the DM/CE incubation medium prior to enzymatic digestion to harvest CECs for the in vivo cell-injection studies. Following SNEC injection, mean central corneal thickness (CCT) of rabbits increased to 802.9 ± 147.8 μm on day 1, gradually thinned, and remained clear with a CCT of 385.5 ± 38.6 μm at week 3. Recovery of corneas was comparable to rabbits receiving cultured CE-CI (p = 0.40, p = 0.17, and p = 0.08 at weeks 1, 2, and 3, respectively). Corneas that did not receive any cells remained significantly thicker compared to both SNEC injection and cultured CE-CI groups (p < 0.05). This study concluded that direct harvesting of single CECs from donor corneas for SNEC injection allows the utilization of donor corneas unsuitable for conventional endothelial transplantation.
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Affiliation(s)
- Hon Shing Ong
- Tissue Engineering and Cell Therapy Group, Singapore Eye Research Institute, Singapore 169856, Singapore; (G.P.); (D.J.H.N.); (H.-P.A.); (K.A.); (C.L.N.); (F.M.-W.); (M.B.); (V.K.)
- Eye-Academic Clinical Program (ACP), Duke-National University of Singapore (NUS), Graduate Medical School, Singapore 169857, Singapore
- Corneal and External Diseases Department, Singapore National Eye Centre, Singapore 168751, Singapore
- Correspondence: (H.S.O.); (J.S.M.); Tel.: +65-6227-7255 (H.S.O. & J.S.M.); Fax: +65-6227-7290 (H.S.O. & J.S.M.)
| | - Gary Peh
- Tissue Engineering and Cell Therapy Group, Singapore Eye Research Institute, Singapore 169856, Singapore; (G.P.); (D.J.H.N.); (H.-P.A.); (K.A.); (C.L.N.); (F.M.-W.); (M.B.); (V.K.)
- Eye-Academic Clinical Program (ACP), Duke-National University of Singapore (NUS), Graduate Medical School, Singapore 169857, Singapore
| | - Dawn Jin Hui Neo
- Tissue Engineering and Cell Therapy Group, Singapore Eye Research Institute, Singapore 169856, Singapore; (G.P.); (D.J.H.N.); (H.-P.A.); (K.A.); (C.L.N.); (F.M.-W.); (M.B.); (V.K.)
| | - Heng-Pei Ang
- Tissue Engineering and Cell Therapy Group, Singapore Eye Research Institute, Singapore 169856, Singapore; (G.P.); (D.J.H.N.); (H.-P.A.); (K.A.); (C.L.N.); (F.M.-W.); (M.B.); (V.K.)
| | - Khadijah Adnan
- Tissue Engineering and Cell Therapy Group, Singapore Eye Research Institute, Singapore 169856, Singapore; (G.P.); (D.J.H.N.); (H.-P.A.); (K.A.); (C.L.N.); (F.M.-W.); (M.B.); (V.K.)
| | - Chan Lwin Nyein
- Tissue Engineering and Cell Therapy Group, Singapore Eye Research Institute, Singapore 169856, Singapore; (G.P.); (D.J.H.N.); (H.-P.A.); (K.A.); (C.L.N.); (F.M.-W.); (M.B.); (V.K.)
| | - Fernando Morales-Wong
- Tissue Engineering and Cell Therapy Group, Singapore Eye Research Institute, Singapore 169856, Singapore; (G.P.); (D.J.H.N.); (H.-P.A.); (K.A.); (C.L.N.); (F.M.-W.); (M.B.); (V.K.)
| | - Maninder Bhogal
- Tissue Engineering and Cell Therapy Group, Singapore Eye Research Institute, Singapore 169856, Singapore; (G.P.); (D.J.H.N.); (H.-P.A.); (K.A.); (C.L.N.); (F.M.-W.); (M.B.); (V.K.)
- Cornea Unit, Guy’s & St Thomas’ Hospital, London SE1 7EH, UK
| | - Viridiana Kocaba
- Tissue Engineering and Cell Therapy Group, Singapore Eye Research Institute, Singapore 169856, Singapore; (G.P.); (D.J.H.N.); (H.-P.A.); (K.A.); (C.L.N.); (F.M.-W.); (M.B.); (V.K.)
- Netherlands Institute for Innovative Ocular Surgery, Melles Cornea Clinic, Amnitrans EyeBank Rotterdam, 3071 AA Rotterdam, The Netherlands
| | - Jodhbir S. Mehta
- Tissue Engineering and Cell Therapy Group, Singapore Eye Research Institute, Singapore 169856, Singapore; (G.P.); (D.J.H.N.); (H.-P.A.); (K.A.); (C.L.N.); (F.M.-W.); (M.B.); (V.K.)
- Eye-Academic Clinical Program (ACP), Duke-National University of Singapore (NUS), Graduate Medical School, Singapore 169857, Singapore
- Corneal and External Diseases Department, Singapore National Eye Centre, Singapore 168751, Singapore
- School of Material Science and Engineering, Nanyang Technological University, Singapore 639798, Singapore
- Correspondence: (H.S.O.); (J.S.M.); Tel.: +65-6227-7255 (H.S.O. & J.S.M.); Fax: +65-6227-7290 (H.S.O. & J.S.M.)
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16
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Singhal D, Sahay P, Goel S, Asif MI, Maharana PK, Sharma N. Descemet membrane detachment. Surv Ophthalmol 2020; 65:279-293. [PMID: 31923476 DOI: 10.1016/j.survophthal.2019.12.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 12/27/2019] [Accepted: 12/30/2019] [Indexed: 10/25/2022]
Abstract
Descemet membrane detachment (DMD) is a potential vision-threatening complication that occurs most commonly after cataract surgery. DMD has also been reported to occur in various other surgeries such as keratoplasty, iridectomy, vitrectomy, trabeculectomy, holmium laser sclerostomy, alkali burn, and viscocanalostomy. Major risk factors include advanced age, preexisting endothelial diseases like Fuchs dystrophy or abnormality in the Descemet membrane and stromal interface, hard cataract, prolonged surgical time, ragged clear corneal incisions, and inadvertent trauma with blunt instruments or phacoemulsification probe. Most DMDs are peripheral and resolve spontaneously. Large, central DMDs if not managed appropriately may lead to corneal decompensation and opacification. Several authors have classified DMD depending on its configuration, height, extent, length, and position with respect to pupil. Anterior segment optical coherence tomography has been used to confirm and classify DMD and can also aid in deciding the management plan. Spontaneous reattachment of the DM with conservative management may occur in cases with small, peripheral, planar DMD with nonscrolled edges. Cases with nonplanar, central DMD, scrolled edges, and length >2 mm, however, have to be managed surgically. Descemetopexy is the gold standard for the management of DMD. Other management options include mechanical tamponade, suture fixation, descemetotomy, interface drainage, and keratoplasty. Prompt diagnosis and timely management often leads to a good visual outcome.
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Affiliation(s)
- Deepali Singhal
- Department of Ophthalmology, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Pranita Sahay
- Department of Ophthalmology, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Siddhi Goel
- Department of Ophthalmology, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Mohamed Ibrahime Asif
- Department of Ophthalmology, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Prafulla K Maharana
- Department of Ophthalmology, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Namrata Sharma
- Department of Ophthalmology, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India.
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17
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Flushing Versus Pushing Technique for Graft Implantation in Descemet Membrane Endothelial Keratoplasty. Cornea 2019; 39:605-608. [DOI: 10.1097/ico.0000000000002239] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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18
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Descemet Membrane Endothelial Keratoplasty Outcomes During the Initial Learning Curve of Cornea Fellows. Cornea 2019; 38:806-811. [DOI: 10.1097/ico.0000000000001957] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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19
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Yoeruek E, Hofmann J, Bartz Schmidt KU. Effectiveness of curvilinear approach in dissection of Descemet's membrane: first 500 cases - factors influencing graft preparation. Acta Ophthalmol 2018; 96:e970-e973. [PMID: 30239156 DOI: 10.1111/aos.13786] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 03/17/2018] [Indexed: 11/30/2022]
Abstract
PURPOSE To confirm the reproducibility of manual graft preparation using curvilinear forceps and evaluate the incidence and type of structural abnormalities of Descemet's membrane (DM) preventing successful grafts preparation. METHODS Five hundred corneo-scleral buttons were prepared. Factors such as endothelial cell number before preparation, donor age, post-mortem time, time in culture, pigmentation of the trabecular meshwork and preparation characteristics of the fellow eye were analysed. According to the preparation characteristics, three groups were formed: A, uncomplicated; B, complicated preparation with stripping from the contralateral side; and C, failure of preparation. Three failed grafts were examined by transmission electron microscopy (TEM). RESULTS Using curvilinear forceps, manual separation of DM was achieved without any adverse effects in 457 of 500 corneas (91.4%). In 32 corneas (6.4%) with micro-tears during preparation, stripping from the opposite side was possible. However, 11 of the 500 corneas (2.2%) showed extremely strong adhesion leading to multiple tears of DM and preventing successful preparation of the graft. Endothelial cell number, donor age, post-mortem time, time in culture and pigmentation of the trabecular meshwork showed no significant correlation with failure to successfully obtain a DM graft. Complicated graft preparations of one eye showed a highly significant correlation with complicated graft preparations in the fellow eye. TEM analysis of failed grafts showed abnormal invasion of stromal parts into the DM, cell accumulation and pigmentation in the DM plane. CONCLUSION Using curvilinear forceps for dissecting of the graft shows valid and reproducible results in the vast majority (97.8%) of donor corneas.
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Affiliation(s)
- Efdal Yoeruek
- Department of Ophthalmology; Eberhard-Karls University; Tuebingen Germany
| | - Johanna Hofmann
- Department of Ophthalmology; Eberhard-Karls University; Tuebingen Germany
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20
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Precut DMEK Using Dextran-Containing Storage Medium Is Equivalent to Conventional DMEK: A Prospective Pilot Study. Cornea 2018; 38:24-29. [PMID: 30325842 DOI: 10.1097/ico.0000000000001778] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
PURPOSE To compare the clinical outcome after Descemet membrane endothelial keratoplasty (DMEK) either as precut or conventional Descemet membrane graft preparation under standard European eye bank organ culture conditions. METHODS This was a prospective pilot study of patients receiving either precut or conventional DMEK. Graft preparation was performed using the liquid bubble technique. Precut grafts (n = 22) were prepared 1 day before surgery in the eye bank and stored in dextran-containing organ culture medium within a transport viewing chamber. Conventional grafts (n = 29) were prepared directly before surgery. End point criteria included the endothelial cell count (ECC), central corneal thickness, graft rejection rate, rebubbling rate, and best-corrected visual acuity after 1, 3, and 6 months. RESULTS A post hoc matched analysis revealed no statistically significant differences between the 2 groups. The ECC in the precut and conventional groups was comparable with an EC loss of 34% and 35%, respectively, after 6 months. The early graft failure rate, best-corrected visual acuity, and central corneal thickness were comparable between the 2 groups. CONCLUSIONS This pilot study shows a comparable clinical outcome after DMEK surgery for precut Descemet membrane grafts versus conventionally prepared grafts, using the liquid bubble preparation technique and storage conditions with dextran-containing medium.
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21
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Abstract
Lamellar keratoplasty (LK) has revolutionized corneal graft surgery in several ways. Deep anterior LK (DALK) has eliminated risk of failure due to endothelial rejection. Endothelial keratoplasty (EK) has almost eliminated induced astigmatism and the “weak” graft–host junction as seen with penetrating keratoplasty (PK) and also reduced the risk of endothelial rejection. LK provided new insights into posterior corneal anatomy that led to better understanding and performance of DALK and to the development of another EK procedure, namely pre-Descemet's EK (PDEK). Surgical procedures for LK were further refined based on the improved understanding and are able to deliver better surgical outcomes in terms of structural integrity and long-term patient satisfaction, reducing the need of further surgeries and minimizing patient discomfort. In most specialist centers, anterior lamellar techniques like DALK and EK techniques like Descemet's stripping EK (DSEK) and Descemet's membrane EK (DMEK) have replaced the full-thickness PK where possible. The introduction of microkeratome, femtosecond laser, and PDEK clamp have made LK techniques easier and more predictable and have led to the innovation of another LK procedure, namely Bowman membrane transplant (BMT). In this article, we discuss the evolution of different surgical techniques, their principles, main outcomes, and limitations. To date, experience with BMT is limited, but DALK has become the gold standard for anterior LK. The EK procedures too have undergone a rapid transition from DSEK to DMEK and PDEK emerging as a viable option. Ultrathin-DSEK may still have a role in modern EK.
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Affiliation(s)
- Nadisha P Singh
- Division of Clinical Neuroscience, University of Nottingham, UK
| | - Dalia G Said
- Queen's Medical Centre, Nottingham University Hospitals NHS Trust; Division of Clinical Neuroscience, University of Nottingham, UK
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22
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Vanathi M. Advances in Cornea. Open Ophthalmol J 2018; 12:130-133. [PMID: 30123377 PMCID: PMC6062899 DOI: 10.2174/1874364101812010130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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23
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Liu Y, Zhang J, Zhang Y, Yin M, Miao S, Liang Q, Pan Z. The feasibility and efficacy of preparing porcine Descemet’s membrane endothelial keratoplasty (DMEK) grafts by two techniques: An ex-vivo investigation for future xeno-DMEK. Xenotransplantation 2018; 25:e12407. [PMID: 29756410 DOI: 10.1111/xen.12407] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Revised: 03/14/2018] [Accepted: 04/13/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Yang Liu
- Beijing Ophthalmology and Visual Sciences Key Laboratory; Beijing Tongren Eye Center; Beijing Tongren Hospital; Capital Medical University; Beijing China
- Department of Ophthalmology; The First Hospital of Lanzhou University; Chengguan District, Lanzhou China
| | - Jing Zhang
- Beijing Ophthalmology and Visual Sciences Key Laboratory; Beijing Tongren Eye Center; Beijing Tongren Hospital; Capital Medical University; Beijing China
| | - Yingnan Zhang
- Beijing Ophthalmology and Visual Sciences Key Laboratory; Beijing Tongren Eye Center; Beijing Tongren Hospital; Capital Medical University; Beijing China
| | - Mingyang Yin
- Beijing Ophthalmology and Visual Sciences Key Laboratory; Beijing Tongren Eye Center; Beijing Tongren Hospital; Capital Medical University; Beijing China
| | - Sen Miao
- Beijing Anzhen Hospital; Capital Medical University; Beijing China
| | - Qingfeng Liang
- Beijing Ophthalmology and Visual Sciences Key Laboratory; Beijing Institute of Ophthalmology; Beijing Tongren Eye Center; Beijing Tongren Hospital; Capital Medical University; Beijing China
| | - Zhiqiang Pan
- Beijing Ophthalmology and Visual Sciences Key Laboratory; Beijing Tongren Eye Center; Beijing Tongren Hospital; Capital Medical University; Beijing China
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24
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Standardizing Descemet Membrane Endothelial Keratoplasty Graft Preparation Method in the Eye Bank-Experience of 527 Descemet Membrane Endothelial Keratoplasty Tissues. Cornea 2018; 36:1458-1466. [PMID: 28968293 DOI: 10.1097/ico.0000000000001349] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To share the experience and provide a standardized protocol for Descemet membrane endothelial keratoplasty (DMEK) graft preparation. METHODS A retrospective study based on 527 prestripped DMEK tissues that were prepared between 2014 and 2017. The experience of using different instruments and techniques has been described, and a standardized technique for preparing DMEK grafts has been identified. The tissues in general were prepared by superficially tapping the endothelial side with a Moria trephine (9.5 mm diameter). The plane of cleavage was identified using a cleavage hook, and the DMEK graft was deadhered from the trephined site throughout the circumference for ease of excising the graft. The DMEK graft was peeled using either one or multiple quadrant methods depending on the challenges faced during excision. The graft was finally marked with the letter "F" to identify the orientation during surgery. Data on endothelial cell loss (ECL) and challenging cases were observed, monitored, and recorded during this period. RESULTS Less than 1 percent trypan blue-positive cells with tissue wastage of <6% was observed during the study period. Our standardized stripping technique has resulted in an overall ECL of 4.6%. Marking Descemet membrane showed 0.5% cell mortality. CONCLUSIONS Standardizing DMEK technique using specific tools and simple techniques would help new surgeons to decide the instruments and improve their tissue preparation skills also in challenging cases such as previous cataract incisions or horseshoe-shaped tears, further reducing ECL or tissue wastage.
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25
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Birbal RS, Sikder S, Lie JT, Groeneveld-van Beek EA, Oellerich S, Melles GRJ. Donor Tissue Preparation for Descemet Membrane Endothelial Keratoplasty: An Updated Review. Cornea 2018; 37:128-135. [PMID: 28990995 DOI: 10.1097/ico.0000000000001368] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To provide an overview of the current literature on donor tissue preparation for Descemet membrane endothelial keratoplasty (DMEK). METHODS A comprehensive database search without date restrictions was performed in PubMed and in The Cochrane Library in May, 2017. Keywords included Descemet membrane endothelial keratoplasty, corneal transplantation, graft, harvest, dissection, preparation, endothelial cell, and endothelial cell density. Articles aiming to describe or evaluate a technique for DMEK graft preparation were considered eligible and were included in this review. RESULTS A graft dissection technique that provides consistent tissue qualities and a low risk of preparation failure is essential for surgeons and eye banks preparing DMEK tissue. Various techniques have been described aiming to facilitate DMEK graft dissection, including manual dissection, pneumatic dissection, and hydrodissection. All show a trend toward a no-touch technique, for example, without direct physical tissue manipulation during tissue harvesting, as a potential ideal approach to minimize graft damage. CONCLUSIONS An overview of the current harvesting techniques available for DMEK may benefit corneal surgeons and eye banks in choosing the best approach for each specific user.
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Affiliation(s)
- Rénuka S Birbal
- Netherlands Institute for Innovative Ocular Surgery, Rotterdam, the Netherlands.,Melles Cornea Clinic Rotterdam, the Netherlands.,Amnitrans Eye Bank Rotterdam, the Netherlands
| | - Shameema Sikder
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jessica T Lie
- Netherlands Institute for Innovative Ocular Surgery, Rotterdam, the Netherlands.,Amnitrans Eye Bank Rotterdam, the Netherlands
| | - Esther A Groeneveld-van Beek
- Netherlands Institute for Innovative Ocular Surgery, Rotterdam, the Netherlands.,Amnitrans Eye Bank Rotterdam, the Netherlands
| | - Silke Oellerich
- Netherlands Institute for Innovative Ocular Surgery, Rotterdam, the Netherlands
| | - Gerrit R J Melles
- Netherlands Institute for Innovative Ocular Surgery, Rotterdam, the Netherlands.,Melles Cornea Clinic Rotterdam, the Netherlands.,Amnitrans Eye Bank Rotterdam, the Netherlands
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26
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Cabrerizo J, Forshaw T, Rodriguez-Aierbe C, Garrido-Fierro J. Scanning electron microscopy assessment of the Descemet membrane interface during DMEK graft preparation. Sci Rep 2018; 8:492. [PMID: 29323218 PMCID: PMC5765053 DOI: 10.1038/s41598-017-18991-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 12/20/2017] [Indexed: 01/11/2023] Open
Abstract
We set out to determine microscopic characteristics of the Descemet membrane interface during Descemet membrane endothelial keratoplasty (DMEK) graft preparation. Ten corneas were partially prepared, preserving half of the Descemet membrane attached to the stroma to enable visualisation of the Descemet-stroma interface. This tissue was prepared for viewing with a scanning electron microscope. The Descemet-stroma interface was categorised into three regions: centre, mid-periphery and periphery. We classified adhesions in these regions as either minor thread-like adhesions or major bridge-like adhesions with stromal detachments. We found a region-specific differentiation of the Descemet-stroma morphology. The presence of minor (P = 0,0001) and major (P = 0,0001) adhesions at the explored regions of the Descemet-stroma interface were found to be statistically significant. Fibrotic linear adhesions were predominant in the centre and mid-periphery, whereas the larger bridge-like adhesions were found mainly in the periphery. In addition, we observed a positive correlation between the size of the adhesions and the presence of ruptures in the underlying stromal bed. Viewing of the Descemet-stroma interface with electron microscopy reveals morphological differences between the centre of a graft and its periphery. These findings are of potential clinical relevance in terms of developing a better understanding of tissue behaviour during graft preparation.
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Affiliation(s)
- Javier Cabrerizo
- Department of Ophthalmology, Rigshospitalet/Glostrup, University of Copenhagen, Copenhagen, Denmark. .,Copenhagen Eye Foundation, Copenhagen, Denmark.
| | - Thomas Forshaw
- Department of Ophthalmology, Zealand University Hospital, Roskilde, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | | | - Jesus Garrido-Fierro
- Department of Ophthalmology, University Hospital of Alava, Vitoria -Gasteiz, Spain
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27
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Deng SX, Lee WB, Hammersmith KM, Kuo AN, Li JY, Shen JF, Weikert MP, Shtein RM. Descemet Membrane Endothelial Keratoplasty: Safety and Outcomes: A Report by the American Academy of Ophthalmology. Ophthalmology 2017; 125:295-310. [PMID: 28923499 DOI: 10.1016/j.ophtha.2017.08.015] [Citation(s) in RCA: 310] [Impact Index Per Article: 38.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 08/09/2017] [Accepted: 08/09/2017] [Indexed: 10/18/2022] Open
Abstract
PURPOSE To review the published literature on the safety and outcomes of Descemet membrane endothelial keratoplasty (DMEK) for the surgical treatment of corneal endothelial dysfunction. METHODS Literature searches were last conducted in the PubMed and the Cochrane Library databases most recently in May 2017. The searches, which were limited to English-language abstracts, yielded 1085 articles. The panel reviewed the abstracts, and 47 were determined to be relevant to this assessment. RESULTS After DMEK surgery, the mean best-corrected visual acuity (BCVA) ranged from 20/21 to 20/31, with follow-up ranging from 5.7 to 68 months. At 6 months, 37.6% to 85% of eyes achieved BCVA of 20/25 or better and 17% to 67% achieved BCVA of 20/20 or better. Mean endothelial cell (EC) loss was 33% (range, 25%-47%) at 6 months. Overall change in spherical equivalent was +0.43 diopters (D; range, -1.17 to +1.2 D), with minimal induced astigmatism of +0.03 D (range, -0.03 to +1.11 D). The most common complication was partial graft detachment requiring air injection (mean, 28.8%; range, 0.2%-76%). Intraocular pressure elevation was the second most common complication (range, 0%-22%) after DMEK, followed by primary graft failure (mean, 1.7%; range, 0%-12.5%), secondary graft failure (mean, 2.2%; range, 0%-6.3%), and immune rejection (mean, 1.9%; range, 0%-5.9%). Overall graft survival rates after DMEK ranged from 92% to 100% at last follow-up. Best-corrected visual acuity after Descemet's stripping endothelial keratoplasty (DSEK) ranged from 20/34 to 20/66 at 9 months. The most common complications after DSEK were graft detachment (mean, 14%; range, 0%-82%), endothelial rejection (mean, 10%; range, 0%-45%), and primary graft failure (mean, 5%; range, 0%-29%). Mean EC loss after DSEK was 37% at 6 months. CONCLUSIONS The evidence reviewed supports DMEK as a safe and effective treatment for endothelial failure. With respect to visual recovery time, visual outcomes, and rejection rates, DMEK seems to be superior to DSEK and to induce less refractive error with similar surgical risks and EC loss compared with DSEK. The rate of air injection and repeat keratoplasty were similar in DMEK and DSEK after the learning curve for DMEK.
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Affiliation(s)
- Sophie X Deng
- Stein Eye Institute, University of California, Los Angeles, Los Angeles, California
| | - W Barry Lee
- Piedmont Hospital and Eye Consultants of Atlanta, Atlanta, Georgia
| | | | - Anthony N Kuo
- Duke Eye Center, Duke University Medical Center, Durham, North Carolina
| | - Jennifer Y Li
- UC Davis Eye Center, University of California, Davis, Sacramento, California
| | | | | | - Roni M Shtein
- Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, Michigan
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Instrument to Enhance Visualization of Descemet Membrane During Graft Preparation for DMEK Surgery. Cornea 2017; 35:904-7. [PMID: 26967111 DOI: 10.1097/ico.0000000000000805] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Descemet membrane (DM) endothelial keratoplasty has improved outcomes of corneal transplantation in patients with corneal endothelial disease. However, the procedure has been criticized for jeopardizing donor tissue during graft preparation. Standardization of this procedure may provide a way toward minimizing tissue loss. For this purpose, we propose the use of a novel tool. METHODS Computerized numerical control milling was used to create a blunt instrument, which was used to remove endothelial cells within a defined area in the periphery of donor corneas. Trypan blue was used to stain denuded DM. Graft preparation was continued as per our standard protocol. Transmission electron microscopy was performed on the treated area, and endothelial cell counts were obtained. RESULTS Use of the modified procedure resulted in delineation of a peripheral band of denuded DM, which readily stained with trypan blue. This provided increased visibility of DM during subsequent steps. Transmission electron microscopy confirmed that no structural deficits of DM were induced. Mean endothelial cell loss (±SD) at 24 hours after preparation was 63 (±130) cells per square millimeter in the group prepared with the use of the new instrument (n = 7), versus 116 (±107) cells per square millimeter in the group prepared without the new instrument (n = 7; P = 0.45). CONCLUSIONS The device presented here enhances visualization of DM during creation of the peripheral margin for subsequent lifting of the margin and stripping of the graft. This may increase success rates and shorten preparation times and learning periods for DM preparation. DM ultrastructure and endothelial cells were not negatively affected.
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Weller JM, Schlötzer-Schrehardt U, Kruse FE, Tourtas T. Splitting of the Recipient's Descemet Membrane in Descemet Membrane Endothelial Keratoplasty-Ultrastructure and Clinical Relevance. Am J Ophthalmol 2016; 172:1-6. [PMID: 27609713 DOI: 10.1016/j.ajo.2016.08.037] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 08/16/2016] [Accepted: 08/30/2016] [Indexed: 11/18/2022]
Abstract
PURPOSE In Descemet membrane endothelial keratoplasty (DMEK), lamellar splitting of the Descemet membrane (DM) may occur during stripping of host DM, leaving residual DM on the recipient's DMEK interface. The purpose of this study was to determine the incidence rate of lamellar splitting of DM during DMEK and to describe the ultrastructure of DM in these eyes. DESIGN Retrospective consecutive case series. METHODS setting: Institutional, single-center. PATIENT POPULATION Total of 664 eyes with Fuchs endothelial corneal dystrophy (FECD) scheduled for primary DMEK. INTERVENTION DMEK. MAIN OUTCOME MEASURES The incidence rate of lamellar DM splitting in the recipients' eyes; ultrastructural alterations of stripped DM specimens (transmission electron microscopy); preoperative best-corrected visual acuity (BCVA), central corneal thickness (CCT), and prevalence of diabetes mellitus. RESULTS Sixty-three of 664 eyes (9.5%) with FECD showed lamellar splitting of DM resulting in the dissociation of 2 separate layers. Transmission electron microscopy revealed accumulations of banded and wide-spaced collagen between the thicker posterior banded layer and the thin anterior banded layer, which is adhesive to the corneal stroma. Lamellar splitting occurred along these abnormal collagen inclusions, demarcating the borderline between both layers of DM. CONCLUSIONS Lamellar DM splitting occurs during DM stripping in almost 10% of eyes with FECD. This phenomenon appears to be caused by abnormal collagenous material deposits at the borderline between anterior and posterior layers of DM.
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Affiliation(s)
- Julia M Weller
- Department of Ophthalmology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany.
| | | | - Friedrich E Kruse
- Department of Ophthalmology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - Theofilos Tourtas
- Department of Ophthalmology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
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Two-photon optical microscopy imaging of endothelial keratoplasty grafts. Graefes Arch Clin Exp Ophthalmol 2016; 255:575-582. [PMID: 27858161 DOI: 10.1007/s00417-016-3543-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 08/06/2016] [Accepted: 10/31/2016] [Indexed: 10/20/2022] Open
Abstract
PURPOSE To investigate the microstructure of endothelial keratoplasty grafts using two-photon optical microscopy. METHODS Six endothelial keratoplasty grafts obtained from human donor corneoscleral tissues and prepared by submerged hydrodissection technique were imaged by two-photon optical microscopy. In each graft, two liquid bubbles were created in order to investigate the presence of a conserved cleavage plane regardless of the volume of posterior stroma that remained attached to Descemet's membrane (DM); the first bubble (bubble A) was generated under DM and the second bubble (bubble B) injection was done in order to obtain a layer of deep stroma that kept the two bubbles separated. Six human donor corneoscleral tissues were used as controls. Second harmonic generation and two-photon emitted fluorescence signals were collected from each specimen. RESULTS Dissection of stroma occurred along the posterior collagen lamellae at variable distance from DM, which ranged between 3 and 16 μm in bubble A and between 23 and 41 μm in bubble B. The residual stroma included, anteriorly, bands of collagen lamellae, and thin bundles of stromal collagen fibrils, posteriorly, which were tightly intertwining with the underlying DM. There was no anatomically distinct plane of separation between these pre-Descemetic stromal collagen bundles and the overlying collagen lamellae with this hydrodissection technique. CONCLUSIONS Two-photon optical microscopy provided label-free high-resolution imaging of endothelial keratoplasty grafts, showing that the most posterior stroma changes organization at approximately 10 μm above the DM. The pre-Descemetic stromal collagen fibrils form an intertwined complex with DM, which cannot be separated using hydrodissection.
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Influence of Ultrastructural Corneal Graft Abnormalities on the Outcome of Descemet Membrane Endothelial Keratoplasty. Am J Ophthalmol 2016; 169:58-67. [PMID: 27318075 DOI: 10.1016/j.ajo.2016.06.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 06/03/2016] [Accepted: 06/06/2016] [Indexed: 11/24/2022]
Abstract
PURPOSE To investigate if ultrastructural alterations in the Descemet membrane (DM) are correlated with the clinical outcome after Descemet membrane endothelial keratoplasty (DMEK). DESIGN Retrospective cohort study. METHODS setting: Institutional, single-center. STUDY POPULATION One hundred and twelve residual DM specimens obtained after DM stripping. MAIN OUTCOME MEASURES Incidence of ultrastructural abnormalities in transmission electron microscopy, graft detachment rate, graft failure rate, best-corrected visual acuity (BCVA), endothelial cell density (ECD), and central corneal thickness (CCT). Examination dates were on the day before DMEK and 1, 3, 6, and 12 months after surgery. RESULTS Abnormalities in the ultrastructure of DM were found in 16 of 112 specimens (14%) (abnormal DM group), comprising deposits of long-spacing collagen, fine filaments (proteoglycans), a posterior collagenous layer, pseudoexfoliative material, and guttae. The secondary graft failure rate was significantly higher in the abnormal DM group compared with the normal DM group (P = .001). There was a trend for an increased graft detachment rate in the abnormal DM group (11/16) compared with the normal DM group (42/96) (P = .103). There was no significant difference in mean CCT and ECD after surgery. Mean CCT in the eyes with graft failure in the abnormal DM group at the last follow-up before regrafting was 850 μm, indicating endothelial failure with stromal edema. CONCLUSION This study reveals a correlation between ultrastructural alterations of DM in donor corneas and the graft failure rate after DMEK. Thus, graft failure after DMEK not only is determined by surgical trauma and postoperative events but may also be influenced by intrinsic, graft-specific features.
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Novel liquid bubble dissection technique for DMEK lenticule preparation. Graefes Arch Clin Exp Ophthalmol 2016; 254:1819-23. [DOI: 10.1007/s00417-016-3377-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Revised: 04/22/2016] [Accepted: 05/02/2016] [Indexed: 10/21/2022] Open
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Marty AS, Burillon C, Desanlis A, Damour O, Kocaba V, Auxenfans C. Validation of an endothelial roll preparation for Descemet Membrane Endothelial Keratoplasty by a cornea bank using "no touch" dissection technique. Cell Tissue Bank 2016; 17:225-32. [PMID: 26934895 DOI: 10.1007/s10561-016-9544-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 02/16/2016] [Indexed: 10/22/2022]
Abstract
Descemet Membrane Endothelial Keratoplasty (DMEK) selectively replaces the damaged posterior part of the cornea. However, the DMEK technique relies on a manually-performed dissection that is time-consuming, requires training and presents a potential risk of endothelial graft damages leading to surgery postponement when performed by surgeons in the operative room. To validate precut corneal tissue preparation for DMEK provided by a cornea bank in order to supply a quality and security precut endothelial tissue. The protocol was a technology transfer from the Netherlands Institute for Innovative Ocular Surgery (NIIOS) to Lyon Cornea Bank, after formation in NIIOS to the DMEK "no touch" dissection technique. The technique has been validated in selected conditions (materials, microscope) and after a learning curve, cornea bank technicians prepared endothelial tissue for DMEK. Endothelial cells densities (ECD) were evaluated before and after preparation, after storage and transport to the surgery room. Microbiological and histological controls have been done. Twenty corneas were manually dissected; 18 without tears. Nineteen endothelial grafts formed a double roll. The ECD loss after cutting was 3.3 % (n = 19). After transportation 7 days later, we found an ECD loss of 25 % (n = 12). Three days after cutting and transportation, we found 2.1 % of ECD loss (n = 7). Histology found an endothelial cells monolayer lying on Descemet membrane. The mean thickness was 12 ± 2.2 µm (n = 4). No microbial contamination was found (n = 19). Endothelial roll stability has been validated at 3 days in our cornea bank. Cornea bank technicians trained can deliver to surgeons an ECD controlled, safety and ready to use endothelial tissue, for DMEK by "no touch" technique, allowing time saving, quality and security for surgeons.
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Affiliation(s)
- Anne-Sophie Marty
- Ophthalmology Department, Edouard Herriot Hospital, 5, place d'Arsonval, 69003, Lyon, France.
| | - Carole Burillon
- Ophthalmology Department, Edouard Herriot Hospital, 5, place d'Arsonval, 69003, Lyon, France
| | - Adeline Desanlis
- Cells and Tissue Bank of Hospices Civils de Lyon, Cornea Bank Department, Edouard Herriot Hospital, 5, place d'Arsonval, 69003, Lyon, France
| | - Odile Damour
- Cells and Tissue Bank of Hospices Civils de Lyon, Cornea Bank Department, Edouard Herriot Hospital, 5, place d'Arsonval, 69003, Lyon, France
| | - Viridiana Kocaba
- Ophthalmology Department, Edouard Herriot Hospital, 5, place d'Arsonval, 69003, Lyon, France
| | - Céline Auxenfans
- Cells and Tissue Bank of Hospices Civils de Lyon, Cornea Bank Department, Edouard Herriot Hospital, 5, place d'Arsonval, 69003, Lyon, France
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Yin J, Veldman PB. Endothelial Keratoplasty: Descemet's Stripping Automated Endothelial Keratoplasty Versus Descemet's Membrane Endothelial Keratoplasty. Int Ophthalmol Clin 2016; 56:167-183. [PMID: 27257730 DOI: 10.1097/iio.0000000000000118] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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Spaniol K, Borrelli M, Holtmann C, Schrader S, Geerling G. Komplikationen der Descemetmembran-Endothel-Keratoplastik. Ophthalmologe 2015; 112:974-81. [DOI: 10.1007/s00347-015-0170-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Feasibility and Outcome of Descemet Membrane Endothelial Keratoplasty in Complex Anterior Segment and Vitreous Disease. Cornea 2015; 34:1351-7. [DOI: 10.1097/ico.0000000000000625] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Dua HS, Faraj LA, Said DG. Dua’s layer: discovery, characteristics, clinical applications, controversy and potential relevance to glaucoma. EXPERT REVIEW OF OPHTHALMOLOGY 2015. [DOI: 10.1586/17469899.2015.1103180] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Feizi S, Javadi MA, Daryabari SH. Factors influencing big-bubble formation during deep anterior lamellar keratoplasty in keratoconus. Br J Ophthalmol 2015; 100:622-5. [PMID: 26311063 DOI: 10.1136/bjophthalmol-2015-307111] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Accepted: 08/08/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE To investigate recipient and operative factors that can influence the rate of achieving a bare Descemet's membrane (DM) during deep anterior lamellar keratoplasty (DALK) for keratoconus. MATERIALS In this retrospective comparative study, a total of 290 (153 right) consecutive eyes from 257 (179 male) keratoconus-affected patients who underwent DALK with the big-bubble technique were enrolled. Univariate analyses and multiple logistic regressions were used to investigate factors including patient age and sex, family history of keratoconus, history of contact lens wear or vernal keratoconjunctivitis, the presence of Vogt's striae or superficial stromal opacities, keratometric readings, corneal diameter, central and peripheral corneal thickness, anterior chamber depth, vitreous length, and trephination size, which could predict achievement of a bare DM. RESULTS The surgery was completed as a DALK in 289 of 290 eyes, and a bare DM was successfully achieved in 229 (79.2%) eyes. The recipient sex and trephination size significantly influenced the success rate of big-bubble formation. Females had decreased odds of achieving a bare DM by 0.44 times (p=0.02). For each 0.1 mm increase in the trephination size, the odds of a successful big-bubble formation increased by 1.36 times (p=0.03). Other investigated factors did not significantly influence the rate of achieving a bare DM. CONCLUSIONS The rate of successful big-bubble formation was 79.2% in keratoconus. Among the different factors, recipient sex and trephination size significantly influenced this rate. Females had a lower probability of big-bubble formation, and a large trephination size was associated with an increase in the probability of achieving a bare DM.
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Affiliation(s)
- Sepehr Feizi
- Department of Ophthalmology, Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Ali Javadi
- Department of Ophthalmology, Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Seyed-Hashem Daryabari
- Department of Ophthalmology, Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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DMEK lenticule preparation using an air dissection technique: central versus peripheral injection. Eur J Ophthalmol 2015; 26:6-11. [PMID: 26109017 DOI: 10.5301/ejo.5000636] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2015] [Indexed: 11/20/2022]
Abstract
PURPOSE To compare 2 sites of air injection to prepare donor lenticules for Descemet membrane (DM) endothelial keratoplasty. METHODS Fifty-one human corneoscleral buttons from donors aged 4 to 57 years were used. Corneoscleral buttons were placed endothelial side up and a 27-G needle was inserted just outside Schwalbe line and advanced immediately beneath the endothelium. Air was injected centrally inside the 8-mm zone (group 1) or peripherally approximately 1 mm in front of the limbus (group 2). Air injection was continued to extend the DM detachment as far as possible into the corneal periphery. Comparisons of central versus peripheral air injection were performed for reproducibility, the rate of usable tissue, and the type and diameter of the acquired bubble. RESULTS The mean donor age was 30.0 ± 12.9 years. A big bubble was achieved following central or peripheral air injection in all cases. A usable donor lenticule (≥ 8.0 mm) was achieved in 95.7% of cases in group 1 and 89.3% of cases in group 2 (p>0.99). Both injection sites were comparable with regard to the diameter of the achieved bubbles (9.57 ± 2.11 mm versus 10.22 ± 2.34 mm, respectively, p = 0.32), the chance of complete DM detachment (39.1% versus 53.6%, respectively, p = 0.25), and the risk of bubble bursting (4.4% versus 7.1%, respectively, p = 0.41). The odds of a type 2 bubble increased by 11.86 for peripheral air injections compared to central injections (p = 0.01). CONCLUSIONS Both injection sites exhibited comparable rates of usable donor lenticules. However, peripheral air injection was more likely to yield stroma-free grafts.
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Clinical and ultrastructural characteristics of graft failure in DMEK: 1-year results after repeat DMEK. Cornea 2015; 34:11-7. [PMID: 25379869 DOI: 10.1097/ico.0000000000000295] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE To evaluate the role of preexisting corneal pathology on the outcome of Descemet membrane endothelial keratoplasty (DMEK), and also to evaluate the long-term outcome of repeat DMEK for graft failure after primary DMEK. METHODS Eighteen patients undergoing repeat DMEK after failed DMEK were enrolled; 9 of 18 patients had successful primary DMEK on the fellow eye. Evaluations included preoperative anterior chamber depth, intraoperative degree of difficulty, transmission electron microscopy images (n = 14), best-corrected visual acuity (BCVA), endothelial cell density, central corneal thickness, corneal volume, and patient satisfaction. RESULTS Surgeries that led to graft failure had a higher intraoperative degree of difficulty compared with successful surgeries (P = 0.002). Eight of 14 failed grafts showed ultrastructural abnormalities, that is, inclusions or deposits of abnormal fibrillar material in Descemet membrane, indicating endothelial dysfunction before transplantation. BCVA on day 10 after surgery was worse in eyes with graft failure compared with successful DMEK (P = 0.008). Median BCVA (logarithm of the minimum angle of resolution) improved from 0.5 before DMEK and 1.9 before repeat DMEK to 0.3 at 1-year follow-up (P = 0.011). One year after repeat DMEK, endothelial cell density (cells/mm2) of donor corneas decreased from 2501 ± 264 to 1373 ± 270 (P < 0.001), central corneal thickness (µm) decreased from 807 ± 160 to 576 ± 178 (P = 0.002), and corneal volume (mm3) decreased from 84.1 ± 13.0 to 64.4 ± 12.5 (P = 0.002). Patient satisfaction showed no difference between primary and repeat DMEK. CONCLUSIONS A preexisting subclinical corneal endothelial dysfunction may contribute to primary DMEK failure. Repeat DMEK can be performed safely with good long-term outcome.
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Descemet membrane endothelial keratoplasty as treatment for graft failure after descemet stripping automated endothelial keratoplasty. Am J Ophthalmol 2015; 159:1050-1057.e2. [PMID: 25790736 DOI: 10.1016/j.ajo.2015.03.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2014] [Revised: 03/10/2015] [Accepted: 03/11/2015] [Indexed: 11/20/2022]
Abstract
PURPOSE To investigate the outcome of Descemet membrane endothelial keratoplasty (DMEK) in patients with graft failure after Descemet stripping automated endothelial keratoplasty (DSAEK). DESIGN Retrospective cohort study. METHODS setting: Institutional. STUDY POPULATION Fifteen eyes of 15 patients that underwent DMEK for graft failure with corneal decompensation following DSAEK were analyzed; 15 eyes with primary DMEK for Fuchs corneal dystrophy were included as control group. MAIN OUTCOME MEASURES Best-corrected visual acuity (BCVA), endothelial cell density (ECD), central corneal thickness (CCT), and rebubbling rate. RESULTS DMEK surgery was successful in all cases of both groups. Mean BCVA (logMAR) before DMEK was 1.27 ± 0.34 in the DMEK after DSAEK group and 1.0 ± 0.40 in the Primary DMEK group. After DMEK, mean BCVA increased significantly to 0.23 ± 0.21 (P = .012, DMEK after DSAEK group) and 0.29 ± 0.23 (P = .042, Primary DMEK group) after 3 months. There were no significant differences in mean BCVA between both groups at each visit. The rebubbling rate was 13% in the DMEK after DSAEK group and 40% in the Primary DMEK group (P = .1). Mean CCT decreased significantly in both groups 1 month after DMEK (P < .05). Mean ECD and change of ECD did not differ significantly between both groups at each visit (P > .05). CONCLUSION The results after DMEK as a procedure to treat graft failure after DSAEK were as good as in patients that underwent DMEK as primary intervention to treat advanced Fuchs dystrophy. This indicates that the optical quality can be reestablished by DMEK in patients with failed DSAEK.
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Villarrubia A, Cano-Ortiz A. [Deep layers of the cornea and basic research in Spain]. ACTA ACUST UNITED AC 2015; 90:301-2. [PMID: 26008930 DOI: 10.1016/j.oftal.2015.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2015] [Revised: 03/10/2015] [Accepted: 03/23/2015] [Indexed: 10/23/2022]
Affiliation(s)
- A Villarrubia
- Instituto de Oftalmología La Arruzafa, Grupo INNOVA, Córdoba, España.
| | - A Cano-Ortiz
- Instituto de Oftalmología La Arruzafa, Grupo INNOVA, Córdoba, España
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Wan KHN, Yiu EPF, Young AL. Corneal transplantation: Beyond the horizon. World J Ophthalmol 2015; 5:36-44. [DOI: 10.5318/wjo.v5.i2.36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Revised: 03/04/2015] [Accepted: 04/02/2015] [Indexed: 02/06/2023] Open
Abstract
Evolving techniques in keratoplasty have undoubtedly led to thinner corneal grafts. These newer iterations of keratoplasty aim to reduce graft rejections, improve visual acuity and visual rehabilitation. Each technique poses its own advantages and disadvantages; the surgeon should select patients suitable for a particular technique while accounting for their surgical competency given the learning curve associated with these newer techniques. Alternatives to corneal transplant may have a role in addressing the shortages of corneal graft, these bioengineered material and medical treatment still need further studies to demonstrate its clinical applicability.
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Comparison of Descemet-On Versus Descemet-Off Deep Anterior Lamellar Keratoplasty in Keratoconus Patients: A Randomized Trial. Cornea 2015; 34:797-801. [PMID: 25933402 DOI: 10.1097/ico.0000000000000444] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To compare the visual outcomes of Descemet membrane (DM)-on and DM-off after deep anterior lamellar keratoplasty (DALK) using the big-bubble (BB) technique in keratoconus patients. METHODS In this prospective trial, keratoconic eyes undergoing DALK procedures with the BB technique were randomized into 2 groups: a donor cornea without DM (group 1; 29 eyes) or with DM (group 2; 30 eyes). These groups were compared with respect to best-corrected visual acuity and contrast sensitivity while wearing gas permeable contact lenses and also endothelial cell counts. RESULTS There were no statistically significant differences between the 2 groups with regard to best-corrected visual acuity and contrast sensitivity using gas permeable contact lenses as well as endothelial cell counts at 3, 6, and 12 months. After 1 year, the mean (±SD) postoperative visual acuity CL (with contact lenses) was 0.05 (±0.01) in the DM-off group and 0.05 (±0.01) in the DM-on group (P = 0.956). Mean postoperative endothelial cell counts were 2425.0 (±123.7) and 2306.7 (79.9), respectively (P = 0.443), and corneal thicknesses were 527.9 (58.3) and 556.6 (47.3), respectively (P = 0.150). During the follow-up period, very few complications occurred and neither group had a predominance of adverse events at 3, 6, 12, or 24 months. CONCLUSIONS In conclusion, DALK procedures using the BB technique for keratoconus with DM-on or DM-off presented no significant differences regarding the visual outcomes or endothelial cell counts.
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Vianna LM, Stoeger CG, Galloway JD, Terry M, Cope L, Belfort R, Jun AS. Risk factors for eye bank preparation failure of Descemet membrane endothelial keratoplasty tissue. Am J Ophthalmol 2015; 159:829-34.e2. [PMID: 25640409 DOI: 10.1016/j.ajo.2015.01.030] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2014] [Revised: 01/25/2015] [Accepted: 01/26/2015] [Indexed: 10/24/2022]
Abstract
PURPOSE To assess the results of a single eye bank preparing a high volume of Descemet membrane endothelial keratoplasty (DMEK) tissues using multiple technicians to provide an overview of the experience and to identify possible risk factors for DMEK preparation failure. DESIGN Cross-sectional study. METHODS setting: Lions VisionGift and Wilmer Eye Institute at Johns Hopkins Hospital. STUDY POPULATION All 563 corneal tissues processed by technicians at Lions VisionGift for DMEK between October 2011 and May 2014 inclusive. OBSERVATION PROCEDURES Tissues were divided into 2 groups: DMEK preparation success and DMEK preparation failure. MAIN OUTCOME MEASURES We compared donor characteristics, including past medical history. RESULTS The overall tissue preparation failure rate was 5.2%. Univariate analysis showed diabetes mellitus (P = .000028) and its duration (P = .023), hypertension (P = .021), and hyperlipidemia or obesity (P = .0004) were more common in the failure group. Multivariate analysis showed diabetes mellitus (P = .0001) and hyperlipidemia or obesity (P = .0142) were more common in the failure group. Elimination of tissues from donors either with diabetes or with hyperlipidemia or obesity reduced the failure rate from 5.2% to 2.2%. Trends toward lower failure rates occurring with increased technician experience also were found. CONCLUSIONS Our work showed that tissues from donors with diabetes mellitus (especially with longer disease duration) and hyperlipidemia or obesity were associated with higher failure rates in DMEK preparation. Elimination of tissues from donors either with diabetes mellitus or with hyperlipidemia or obesity reduced the failure rate. In addition, our data may provide useful initial guidelines and benchmark values for eye banks seeking to establish and maintain DMEK programs.
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Safety of donor tissue preparation and use of descemetoschisis and torn tissue in descemet membrane endothelial keratoplasty. Cornea 2015; 33:e7-9. [PMID: 25090167 DOI: 10.1097/ico.0000000000000208] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Lass JH, Riddlesworth TD, Gal RL, Kollman C, Benetz BA, Price FW, Sugar A, Terry MA, Soper M, Beck RW. The effect of donor diabetes history on graft failure and endothelial cell density 10 years after penetrating keratoplasty. Ophthalmology 2015; 122:448-56. [PMID: 25439611 PMCID: PMC4339512 DOI: 10.1016/j.ophtha.2014.09.012] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Revised: 08/04/2014] [Accepted: 09/11/2014] [Indexed: 10/24/2022] Open
Abstract
OBJECTIVE To examine the long-term effect of donor diabetes history on graft failure and endothelial cell density (ECD) after penetrating keratoplasty (PK) in the Cornea Donor Study. DESIGN Multicenter, prospective, double-masked, controlled clinical trial. PARTICIPANTS One thousand ninety subjects undergoing PK for a moderate risk condition, principally Fuchs' dystrophy or pseudophakic or aphakic corneal edema, were enrolled by 105 surgeons from 80 clinical sites in the United States. METHODS Corneas from donors 12 to 75 years of age were assigned by 43 eye banks to participants without respect to recipient factors. Donor and recipient diabetes status was determined from existing medical records. Images of the central endothelium were obtained before surgery (baseline) and at intervals for 10 years after surgery and were analyzed by a central image analysis reading center to determine ECD. MAIN OUTCOME MEASURES Time to graft failure (regraft or cloudy cornea for 3 consecutive months) and ECD. RESULTS There was no statistically significant association of donor diabetes history with 10-year graft failure, baseline ECD, 10-year ECD, or ECD values longitudinally over time in unadjusted analyses, nor after adjusting for donor age and other significant covariates. The 10-year graft failure rate was 23% in the 199 patients receiving a cornea from a donor with diabetes versus 26% in the 891 patients receiving a cornea from a donor without diabetes (95% confidence interval for the difference, -10% to 6%; unadjusted P=0.60). Baseline ECD (P=0.71), 10-year ECD (P>0.99), and changes in ECD over 10 years (P=0.86) were similar comparing donor groups with and without diabetes. CONCLUSIONS The study results do not suggest an association between donor diabetes and PK outcome. However, the assessment of donor diabetes was imprecise and based on historical data only. The increasing frequency of diabetes in the aging population in the United States affects the donor pool. Thus, the impact of donor diabetes on long-term endothelial health after PK or endothelial keratoplasty, or both, warrants further study with more precise measures of diabetes and its complications.
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Affiliation(s)
- Jonathan H Lass
- Case Western Reserve University, Department of Ophthalmology and Visual Sciences, and University Hospitals Eye Institute, Cleveland, Ohio.
| | | | - Robin L Gal
- Jaeb Center for Health Research, Tampa, Florida
| | | | - Beth A Benetz
- Case Western Reserve University, Department of Ophthalmology and Visual Sciences, and University Hospitals Eye Institute, Cleveland, Ohio
| | | | - Alan Sugar
- W. K. Kellogg Eye Center, University of Michigan, Ann Arbor, Michigan
| | | | - Mark Soper
- Indiana Lions Eye Bank, Indianapolis, Indiana
| | - Roy W Beck
- Jaeb Center for Health Research, Tampa, Florida
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Abstract
Corneal transplantation is one of the most common types of human transplant surgery. By removing a scarred or damaged host cornea and replacing it with a clear and healthy donor transplant, this procedure helps to restore vision in a variety of corneal diseases. The traditional technique for corneal transplantation, penetrating keratoplasty (PKP), involves transplantation of all corneal layers. Over the past decade though, there has been a trend away from PKP as surgeons have developed partial thickness transplant procedures, such as deep anterior lamellar keratoplasty and Descemet stripping automated endothelial keratoplasty. These partial thickness transplant procedures selectively replace diseased host corneal tissue, while conserving healthy and functioning tissue. This review describes current surgical techniques in the field of corneal transplantation, with special emphasis on indications for transplantation and postoperative outcomes.
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Affiliation(s)
- Grace E Boynton
- Department of Ophthalmology and Visual Sciences, University of Michigan Medical School, Kellogg Eye Center, 1000 Wall St., Ann Arbor, MI 48105, USA
| | - Maria A Woodward
- Department of Ophthalmology and Visual Sciences, University of Michigan Medical School, Kellogg Eye Center, 1000 Wall St., Ann Arbor, MI 48105, USA
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Arbelaez JG, Feng MT, Pena TJ, Price MO, Price FW. A year of cornea in review: 2013. Asia Pac J Ophthalmol (Phila) 2015; 4:40-50. [PMID: 26068612 DOI: 10.1097/apo.0000000000000110] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE The goal of this study was to provide an update of significant corneal literature published in 2013. DESIGN This study is a systematic literature review. METHODS We conducted a systematic review of the English-language literature published from January 1, 2013, to December 31, 2013, using the following PubMed search and Medical Subject Headings terms: cornea transplantation, keratoplasty, Descemet membrane endothelial keratoplasty, Descemet stripping endothelial keratoplasty, cross linking, pre-Descemet's layer, Rho-associated kinase, keratoprosthesis, infectious keratitis, corneal dystrophy, corneal astigmatism, and keratoconus. RESULTS This review summarizes relevant and innovative original articles, review articles, and novel techniques from the following journals: American Journal of Ophthalmology, British Journal of Ophthalmology, Cornea, Graefe's Archive for Clinical and Experimental Ophthalmology, Investigative Ophthalmology & Visual Science, JAMA Ophthalmology, Journal of Cataract and Refractive Surgery, Journal of Refractive Surgery, and Ophthalmology. Case reports, abstracts, letters to the Editor, and unpublished work were excluded, as well as articles e-published ahead of print in 2012 that were discussed in the previous review. One hundred twenty-seven articles met the criteria for this review. CONCLUSIONS This review summarizes significant cornea-related literature from 2013.
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Affiliation(s)
- Juan G Arbelaez
- From the *Price Vision Group; and †Cornea Research Foundation of America, Indianapolis, IN
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