Abstract Traditionally, the mainstay of treatment for advanced keratoconus (KC) has been either penetrating or deep anterior lamellar keratoplasty (PK or DALK, respectively). The success of both ...operations, however, has been somewhat tempered by potential difficulties and complications, both intraoperatively and postoperatively. These include suture and wound-healing problems, progression of disease in the recipient rim, allograft reaction, and persistent irregular astigmatism. Taken together, these have been the inspiration for an ongoing search for less troublesome therapeutic alternatives. These include ultraviolet crosslinking and intracorneal ring segments, both of which were originally constrained in their indication exclusively to eyes with mild to moderate disease. More recently, Bowman layer transplantation has been introduced for reversing corneal ectasia in eyes with advanced KC, re-enabling comfortable contact lens wear and permitting PK and DALK to be postponed or avoided entirely. We offer a summary of the current and emerging treatment options for advanced KC, aiming to provide the corneal specialist useful information in selecting the optimal therapy for individual patients.
Summary
Thoracic endovascular aortic repair (TEVAR) has emerged as a promising therapeutic alternative to conventional open aortic replacement but it requires suitable proximal and distal landing ...zones for stent-graft anchoring. Many aortic pathologies affect in the immediate proximity of the left subclavian artery (LSA) limiting the proximal landing zone site without proximal vessel coverage. In patients in whom the distance between the LSA and aortic lesion is too short, extension of the landing zone can be obtained by covering the LSA's origin with the endovascular stent graft (ESG). This manoeuvre has the potential for immediate and delayed neurological and vascular symptoms. Some authors, therefore, propose prophylactic revascularisation of the LSA by transposition or bypass, while others suggest prophylactic revascularisation only under certain conditions, and still others see no requirement for prophylactic revascularisation in anticipation of LSA ostium coverage. In this review about LSA revascularisation in TEVAR patients with coverage of the LSA, we searched the electronic databases MEDLINE and EMBASE historically until the end date of May 2010 with the search terms left subclavian artery, covering, endovascular, revascularisation and thoracic aorta. We have gathered the most complete scientific evidence available used to support the various concepts to deal with this issue. After a review of the current available literature, 23 relevant articles were found, where we have identified and analysed three basic treatment concepts for LSA revascularisation in TEVAR patients (prophylactic, conditional prophylactic and no prophylactic LSA revascularisation). The available evidence supports prophylactic revascularisation of the LSA before ESG LSA coverage when preoperative imaging reveals abnormal supra-aortic vascular anatomy or pathology. We further conclude that elective patients undergoing planned coverage of the LSA during TEVAR should receive prophylactic LSA transposition or LSA-to-left-common-carotid-artery (LCCA) bypass surgery to prevent severe neurological complications, such as paraplegia or brain stem infarction.
To describe discrepancies between clinical observation and current teachings in corneal endothelial disease, particularly in Fuchs endothelial dystrophy and its potential association with primary ...open angle glaucoma.
Perspective.
A perspective is presented on Fuchs dystrophy, a disorder that commonly presents with a compromised endothelium but minimal stromal edema, indicating that the corneal imbibition pressure is relatively “too high.”
The discrepancy between the relative lack of stromal edema in the absence of an endothelial cell layer cannot be explained by the current theories involving a circulatory pumping mechanism over the endothelial cell layer, but may point to the following: (1) secondary involvement of the corneal endothelium in Fuchs dystrophy; (2) separate hydration systems for maintaining the imbibition pressure (vertical static hydration) and corneal nutrition (horizontal dynamic hydration); (3) the cornea as net contributor of aqueous humor; (4) a close relationship between the corneal imbibition and intraocular pressure, with potentially a shared regulatory system; and (5) a potential steroid-type hormone dependency of this regulatory system.
Clinical observation shows that the stromal imbibition pressure is “too high” in Fuchs endothelial dystrophy, indicating that it may not primarily be an endothelial disease, but a type of “corneal glaucoma.”
The purpose of this study was to describe the incidence of graft detachment after Descemet membrane endothelial keratoplasty (DMEK) without postoperative supine posturing.
A total of 106 eyes of 84 ...patients with Fuchs endothelial corneal dystrophy or bullous keratopathy (BK) were operated by a single experienced surgeon with DMEK with a 99% anterior chamber air bubble fill, recovered in an upright (seated) position, and then discharged without instructions to remain supine. Postoperatively, all eyes were evaluated for graft detachment through anterior segment optical coherence tomography at predetermined intervals (1 d, 1 wk, and 1 mo). Detachments were regarded as clinically significant if they subtended 30% of the total graft surface area or involved the visual axis.
Clinically significant graft detachments were observed in 23 of 106 eyes (22%) in the no-supine posturing cohort, including 22 of 85 eyes (26%) operated for Fuchs endothelial corneal dystrophy and 1 of 21 eyes (5%) operated for BK. Compared with a historical comparison group of eyes undergoing DMEK with 48 hours of postoperative supine posturing, the risk of graft detachment was not increased. In both cohorts, 6% of operated eyes required regrafting for either persistent detachment or primary graft failure. No additional intraoperative or postoperative complications were experienced.
Particularly in eyes operated for BK, the supine posturing requirement after DMEK may be eliminated without increasing the absolute risk for clinically significant graft detachment.
Cumulative anthropogenic impacts such as overfishing, and climate change are placing marine ecosystems under increasing pressure. This includes the loss or degradation of marine habitats and ...reductions in fish stocks, with conservation and fisheries management strategies aiming to mitigate, or reverse the effects. Measuring the effectiveness of management actions on fish requires accurate data on the abundance and size of fishes. Diver operated stereo-video systems (stereo-DOVs) have become a widely accepted method for surveying reef fish but have known biases and constraints. A new generation of small and affordable remotely operated vehicles (ROVs) can carry a stereo-video system to collect reef fish data without the need for divers. However, before ROVs are adopted there is a need to understand how they compare to other conventional survey methods. We compared how stereo-DOVs and stereo-ROVs influenced fish behaviour and sampled coral reef fish assemblages inside and outside sanctuary zones in the Ningaloo Marine Park, Northern Western Australia. In general, the numbers of species, individuals and the assemblage composition did not differ significantly between survey techniques and detected consistent patterns in the assemblage composition across locations and inside and outside sanctuary zones. Both methods recorded similar proportions of length measurements (68% and 70% for stereo-DOV and stereo-ROV respectively). Fishes were significantly more wary and exhibited more flight responses towards stereo-DOVs when compared to stereo-ROVs. The use of ROVs has the potential to be a cost-effective method of surveying reef fish while eliminating the health and safety risks involved with SCUBA diving. Given the comparable metrics as well as reduced behavioural bias and logistical advantages of using stereo-ROVs, we recommend stereo-ROVs as a viable alternative to stereo-DOVs surveys.
•Fish assemblage composition sampled Stereo-DOVs and stereo-ROV was similar.•Both techniques record similar numbers of species and fish individual.•Fish allowed the Stereo-ROVs to approach them closer than stereo-DOVs.•Stereo-ROV is a cost-effective alternative to stereo-DOVs.•Stereo-ROV can operate deeper, with less health and safety risks then stereo-DOVS.
Corneal allogenic intrastromal ring segments (CAIRS) are semicircular pieces of donor corneal stroma, which may be surgically implanted to flatten keratoconic corneas. These segments can be trimmed ...to different thicknesses; whereas thicker segments confer greater flattening, their bulk renders them more technically challenging to insert. Consequently, thinner segments are often preferred, especially for starting surgeons. Here, we describe a technique for transiently thinning CAIRS to facilitate easy insertion, thereby permitting the use of thicker segments to achieve the maximal flattening effect.
Corneal allogenic ring segments (CAIRS) are semicircular pieces of donor corneal stroma which may be surgically implanted to flatten keratoconic corneas. Conventionally, these donor segments are ...inserted into channels created via femtosecond laser dissection. However, access to femtosecond technology is not universal. Here we describe an alternate, manual technique for channel creation which is femtosecond laser independent.
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