To review the management of limbal stem cell deficiency (LSCD) from a historical perspective, report the current treatment guidelines, and propose potential future treatments.
A literature review was ...conducted to identify key publications regarding the management of LSCD since treatments were first reported. The advances in surgical treatments, as well as postoperative management, are described from a historical perspective. In addition, current treatment guidelines, as well as future management strategies, are discussed.
The management of LSCD has changed dramatically during the last several decades. Before the understanding of the anatomy and physiology of the limbus, all patients with severe LSCD had a dismal prognosis. It was not until the understanding of the location and function of the limbal stem cells that successful management protocols could be formulated. This research gave rise to medical and surgical treatment that protected or replaced diseased or absent limbal stem cells. Understanding the role of the conjunctiva in severe ocular surface disease was also critical in the management of LSCD. Continued improvement in tissue harvesting and surgical techniques have led to improved outcomes in LSCD patients.
Significant progress has been made during the last several decades to manage patients with LSCD. A substantial percent of patients can achieve improved visual acuity with current techniques. Continued research with new cell culture and tissue engineering techniques may be the next breakthrough to improve the outcomes for these most challenging patients.
Corneal transplantation Tan, Donald TH, Dr; Dart, John KG, DM; Holland, Edward J, MD ...
The Lancet (British edition),
2012-May-05, Letnik:
379, Številka:
9827
Journal Article
Recenzirano
Summary Corneal transplantation or keratoplasty has developed rapidly in the past 10 years. Penetrating keratoplasty, a procedure consisting of full-thickness replacement of the cornea, has been the ...dominant procedure for more than half a century, and successfully caters to most causes of corneal blindness. The adoption by specialist surgeons of newer forms of lamellar transplantation surgery, which selectively replace only diseased layers of the cornea, has been a fundamental change in recent years. Deep anterior lamellar keratoplasty is replacing penetrating keratoplasty for disorders affecting the corneal stromal layers, while eliminating the risk of endothelial rejection. Endothelial keratoplasty, which selectively replaces the corneal endothelium in patients with endothelial disease, has resulted in more rapid and predictable visual outcomes. Other emerging therapies are ocular surface reconstruction and artificial cornea (keratoprosthesis) surgery, which have become more widely available because of rapid advances in these techniques. Collectively, these advances have resulted in improved outcomes, and have expanded the number of cases of corneal blindness, which can now be treated successfully. Femtosecond-laser-assisted surgery, bioengineered corneas, and medical treatment for endothelial disease are also likely to play a part in the future.
Conjunctivitis, or inflammation of the conjunctiva, is a common condition that can be caused by infectious (eg, bacterial or viral infections) and noninfectious (eg, allergy) etiologies. Treatment ...involves diagnosis of the underlying cause and use of appropriate therapies. A broad-spectrum therapy that can address multiple etiologies, and also the accompanying inflammation, would be very useful. In this review, we discuss the usefulness of topical ophthalmic corticosteroids and ophthalmic formulations that combine corticosteroids with anti-infectives/antibiotics for treating acute infectious conjunctivitis.
A review of the published literature and relevant treatment guidelines.
Topical corticosteroids are useful in treating ocular inflammation, but most treatment guidelines recommend steroid use generally in severe cases of conjunctivitis. This is partly due to risks associated with steroid use. These risks include potential for prolonging adenoviral infections and potentiating/worsening herpes simplex virus infections, increased intraocular pressure, glaucoma, and cataracts. Most of these perceived risks are not, however, supported by high-quality clinical data. They are also associated with long-term steroid uses that are dissimilar to applications for infectious conjunctivitis. Clinical data show that ophthalmic formulations that combine corticosteroids with broad-spectrum anti-infectives could be effective and well tolerated when used for short-term treatment (≤2 weeks).
Corticosteroids, in combination with anti-infectives, could be a promising treatment option for acute conjunctivitis subject to development of further evidence on their effectiveness and safety in conjunctivitis treatment.
Ophthalmology 3: Corneal transplantation Tan, Donald T H; Dart, John K G; Holland, Edward J ...
The Lancet (British edition),
05/2012, Letnik:
379, Številka:
9827
Journal Article
Recenzirano
Corneal transplantation or keratoplasty has developed rapidly in the past 10 years. Penetrating keratoplasty, a procedure consisting of full-thickness replacement of the cornea, has been the dominant ...procedure for more than half a century, and successfully caters to most causes of corneal blindness. The adoption by specialist surgeons of newer forms of lamellar transplantation surgery, which selectively replace only diseased layers of the cornea, has been a fundamental change in recent years. Deep anterior lamellar keratoplasty is replacing penetrating keratoplasty for disorders aff ecting the corneal stromal layers, while eliminating the risk of endothelial rejection. Endothelial keratoplasty, which selectively replaces the corneal endothelium in patients with endothelial disease, has resulted in more rapid and predictable visual outcomes. Other emerging therapies are ocular surface reconstruction and artifi cial cornea (keratoprosthesis) surgery, which have become more widely available because of rapid advances in these techniques. Collectively, these advances have resulted in improved outcomes, and have expanded the number of cases of corneal blindness, which can now be treated successfully. Femtosecond-laser-assisted surgery, bio engineered corneas, and medical treatment for endothelial disease are also likely to play a part in the future. PUBLICATION ABSTRACT
Drug-Induced Corneal Epithelial changes Raizman, Michael B., MD; Hamrah, Pedram, MD; Holland, Edward J., MD ...
Survey of ophthalmology,
05/2017, Letnik:
62, Številka:
3
Journal Article
Recenzirano
Odprti dostop
Abstract Drugs across many pharmacologic classes induce corneal epithelial changes. Many of these drugs have cationic amphiphilic structures, with a hydrophobic ring and hydrophilic cationic amine ...side chain that allow them to cross cell membranes. These drugs lead to intracellular phospholipid accumulation, often manifested in the cornea by vortex keratopathy, with no effect on visual acuity and few ocular symptoms. Other drugs, notably antineoplastic agents, produce a fine diffuse corneal haze, sometimes accompanied by decreased vision that can be dose limiting. Still other medications cause crystalline epithelial precipitation that might require debridement for resolution. An understanding of the variety of drugs involved, the multiple mechanisms responsible, and the systemic diseases that produce similar changes can lead to improved management strategies for patients with corneal epithelial deposits. In most cases drug therapy need not be modified or discontinued, but if visual acuity is affected, close collaboration with the prescribing physician can result in determining an optimized dose that treats systemic disease and minimizes these deposits. Additionally, close monitoring might be required if the drug is also associated with other ocular findings, such as optic neuropathy or retinopathy.
To evaluate visual acuity outcomes after endothelial keratoplasty (EK) and describe the relationship to postoperative central corneal graft thickness as measured by anterior segment optical coherence ...tomography (AS-OCT).
A retrospective case series of 33 eyes in 28 patients undergoing routine EK using precut eye bank tissue was designed. All patients underwent serial central graft thickness measurements with AS-OCT. Based on the median central graft thickness of all patients, the eyes were divided into 2 groups: thin EK and thick EK. Differences between the groups were compared.
The median postoperative graft thickness of all eyes was 131 μm. The eyes were divided into 2 groups based on this median: thin EK (graft thickness: ≤ 131 μm; range: 77-131 μm; average: 109 μm) and thick EK (graft thickness: > 131 μm; range: 138-182 μm; average: 162 μm). There was no statistically significant difference in age, sex, or preoperative best spectacle-corrected visual acuity (BSCVA) between the 2 groups. Average postoperative follow-up was 12.8 months. The thin EK group showed better postoperative BSCVA compared with the thick EK group (P < 0.01). All thin EK eyes had BSCVA greater than or equal to 20/25 with 71% of eyes achieving BSCVA of 20/20. In contrast, only 50% of thick EK eyes reached BSCVA greater than or equal to 20/25 with 19% obtaining BSCVA of 20/20.
Thin EK versus thick EK, as measured by AS-OCT in the postoperative period, showed a statistically significant improvement in BSCVA.
Lifitegrast is a lymphocyte function-associated antigen-1 antagonist developed to reduce inflammation in dry eye disease (DED). We report the results of OPUS-3 (NCT02284516), a phase III study ...evaluating the efficacy and safety of lifitegrast versus placebo in participants with DED.
Twelve-week, phase III, randomized, double-masked, multicenter, placebo-controlled study.
Adults aged ≥18 years with Schirmer tear test (without anesthesia) ≥1 and ≤10 mm, corneal fluorescein staining score ≥2.0 (0-4 scale), eye dryness score (EDS) ≥40 (0-100 visual analogue scale VAS), and history of artificial tear use within 30 days of study entry.
After a 14-day placebo run-in, participants were randomized 1:1 to lifitegrast ophthalmic solution 5.0% or placebo twice daily for 84 days.
The primary efficacy end point was change from baseline to day 84 in EDS. Key secondary efficacy end points were change from baseline to days 42 and 14 in EDS. Other secondary efficacy end points included additional VAS items (burning/stinging, itching, foreign body sensation, eye discomfort, photophobia, pain), ocular discomfort score (ODS), and safety/tolerability of lifitegrast versus placebo.
In the study, 711 participants were randomized: placebo, 356; lifitegrast, 355 (intention-to-treat ITT population). At day 84, lifitegrast-treated participants experienced significantly greater improvement from baseline in EDS versus those receiving placebo (treatment effect TE, 7.16; 95% confidence interval CI, 3.04-11.28; P = 0.0007). Mean changes from baseline in EDS also significantly favored lifitegrast on days 42 (TE, 9.32; 95% CI, 5.44-13.20; P < 0.0001) and 14 (TE, 7.85; 95% CI, 4.33-11.37; P < 0.0001). No statistically significant differences were observed in ODS between treatment groups at days 84, 42, or 14. A greater improvement was observed in lifitegrast-treated participants at day 42 in itching (nominal P = 0.0318), foreign body sensation (nominal P = 0.0418), and eye discomfort (P = 0.0048) versus participants receiving placebo. Most treatment-emergent adverse events were mild to moderate in severity; no serious ocular adverse events were reported.
Lifitegrast significantly improved symptoms of eye dryness, as measured by EDS, versus placebo in participants with DED. Improvement in EDS was observed as early as day 14. Lifitegrast appeared well tolerated.
The purpose of this study was to report a case of acute corneal epithelial rejection of living-related conjunctival limbal allograft (LR-CLAL) after severe acute respiratory syndrome coronavirus 2 ...(SARS-CoV-2) vaccination.
A 27-year-old woman developed acute epithelial rejection of LR-CLAL 2 weeks after receiving the SARS-CoV-2 vaccine. She received the LR-CLAL transplant 4 years and 7 months previously and had a stable clinical course with no history of rejection. She had an ABO blood group and human leukocyte antigen compatible donor, no systemic comorbidities, and no rejection risk factors.
The novel SARS-CoV-2 vaccine upregulates the immune system to produce an adaptive immune response. The SARS-CoV-2 vaccine may potentially be associated with increased risk of rejection in those with ocular surface transplants.
To compare the visual outcomes and complications between nanothin Descemet stripping automated endothelial keratoplasty (NT-DSAEK) and Descemet membrane endothelial keratoplasty (DMEK).
A prospective ...comparative case series of 28 consecutive cases of NT-DSAEK (less than or equal to 50 μm) and DMEK was undertaken. Inclusion criteria were a diagnosis of Fuchs dystrophy, presence of pseudophakia, or planned combined cataract surgery/endothelial keratoplasty, with a minimum of 6-month follow-up. Exclusion criteria were any concurrent ocular comorbidities. Primary outcomes measures were best spectacle-corrected visual acuity (BSCVA) and complications.
Mean thickness of NT-DSAEK grafts was 41.0 ± 7.5 μm (range 26-50 μm). At 1 month postoperatively, the DMEK group had significantly better mean BSCVA of 0.18 ± 0.20 logarithm of the minimum angle of resolution (logMAR) (20/33) compared with 0.28 ± 0.16 logMAR (20/40) for NT-NSAEK (P = 0.049). At 3, 6, and 12 months postoperatively, mean BSCVA was comparable between both groups 3 months: NT-DSAEK 0.17 ± 0.12 logMAR (20/30) versus DMEK 0.13 ± 0.17 (20/27), P = 0.31; 6 months: NT-DSAEK 0.11 ± 0.10 logMAR (20/26) versus DMEK 0.09 ± 0.10 (20/25), P = 0.63; 12 months: NT-DSAEK 0.07 ± 0.09 logMAR (20/24) versus DMEK 0.07 ± 0.11 logMAR (20/24), P = 0.95. Other than 1 NT-DSAEK graft that was successfully rebubbled, no other complications were encountered in either group.
Compared with DMEK, NT-DSAEK provides comparable visual outcomes and complications rates.
The purpose of this study was to report a retrospective case series of anterior scleral and limbal inflammatory necrosis after adjuvant miltefosine for recalcitrant Acanthamoeba keratitis (AK).
A ...case series and literature review.
Four eyes of 3 patients with recalcitrant AK developed anterior scleral and limbal inflammatory necrosis with significant scleral-limbal thinning after treatment with miltefosine. The average age was 38 years, and the average duration of infection before miltefosine treatment was 239 days. All cases required urgent surgical intervention to either prevent or mitigate corneal-limbal perforation.
Miltefosine has been observed to result in the resolution of AK when used as an adjunctive therapy. It may also lead to a consecutive inflammatory necrosis of the anterior sclera and limbus. This inflammatory response may be significant enough to cause rapid scleral-limbal thinning with subsequent perforation.
PDF
