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Soft Contact Lens Wear–Related Limbal Stem Cell Deficiency
December AJO
Shen et al. reported on the outcomes of limbal stem cell (LSC) transplantation in eyes with LSC deficiency related to soft contact lens wear in patients who did not respond to more conservative measures. They found that LSC transplantation before the onset of subepithelial fibrosis yielded good outcomes and avoided subsequent corneal transplantation.
A database search at the Cincinnati Eye Institute revealed 9 patients (14 eyes) who had undergone LSC transplantation for soft contact lens wear–related LSC deficiency. The average patient age at time of surgery was 46.6 ± 11.1 years, and the average duration of follow-up was 28 ± 19.1 months. Preoperative best-corrected visual acuity (BCVA) was 20/40 or worse in all eyes, and symptoms included foreign body sensation, tearing, redness, and pain. Four eyes (29%) received a living-related conjunctival limbal allograft, and 10 eyes (71%) received a cadaver donor keratolimbal allograft. Topical and systemic immunosuppression, including steroids and steroid-sparing agents, was administered to all patients.
At final follow-up, the ocular surface was stable in 12 of 14 eyes (86%). All patients except 1 achieved a BCVA of 20/30 or better as well as complete resolution of symptoms. The only patient who did not experience these improvements had significant rosacea blepharokeratoconjunctivitis. The most common adverse event was an increase in intraocular pressure in 8 of 14 eyes (57%), requiring topical antiglaucoma treatment. Ten of 14 eyes (71%) underwent cataract extraction related to steroid use. No eyes required subsequent penetrating keratoplasty.
The authors concluded that LSC transplantation is a viable option for the management of soft contact lens wear–related LSC deficiency in otherwise healthy patients, when undertaken prior to development of subepithelial fibrosis. Comanagement with a solid-organ transplant specialist is helpful for monitoring and managing systemic adverse events related to systemic immunosuppression.
Corneal Cross-linking to Halt Progression of Keratoconus and Ectasia
December AJO
In a study conducted in the United Kingdom, O’Brart et al. used a retrospective cohort design to determine the long-term efficacy and safety of corneal cross-linking (CXL) in halting the progression of keratoconus and corneal ectasia. Long-term follow-up showed that CXL benefits were maintained, and no treated eyes had progressed, at 7 years.
Thirty-six patients (36 eyes) who had undergone epithelium-off CXL 6 to 8 years previously were examined. At a mean follow-up of 7 years, mean spherical equivalent refractive error increased by +0.78 D, and mean simulated topographic keratometry (SimK) and mean maximum keratometry (Kmax) were reduced by –0.74 D and –0.91 D, respectively, compared with preoperative values. Uncorrected distance acuity and corrected distance visual acuity (CDVA) had improved; and root mean square (RMS), coma, and secondary astigmatism had lessened. At 7 years compared with 1 year postoperatively, CDVA had improved; mean SimK and mean Kmax were reduced by –0.45 D and –0.56 D, respectively; and RMS and coma had decreased. At 7 years compared with 5 years postop, CDVA had improved and trefoil was reduced. In 29 initially untreated fellow eyes, mean SimK and mean Kmax increased by +0.54 D and +0.87 D, respectively; and refractive astigmatism increased.
The authors concluded that in CXL-treated eyes, topographic and wavefront parameter benefits seen at 1 year continued to improve at 5 years and were maintained at 7 years. No treated eyes progressed over the follow-up period, and no sight-threatening complications were reported.
Retained Lens Fragments in the Anterior Chamber After Phaco
December AJO
Zavodni et al. reviewed the clinical features, treatments, and outcomes of patients with retained lens fragments in the anterior chamber (AC) after phacoemulsification with an intact posterior capsule.
Fifty-four eyes of 54 patients with a diagnosis of retained lens fragment in the AC following otherwise uncomplicated phacoemulsification cataract surgery were included. All lens fragments were located in the inferior angle or the inferior AC, with 13% of cases requiring gonioscopy for diagnosis. Among the 54 eyes, 56% had associated corneal edema, most often located inferiorly. Medical management was initially attempted in 44%, but all eyes eventually underwent surgical removal of the lens fragments.
The mean time between the date of cataract surgery and removal of the fragments was 70 days (range, 1 day to 30 months). Five patients had corneal edema that did not resolve following fragment extraction, and 3 eventually received an endothelial keratoplasty. Best-corrected visual acuity improved from an average of 20/51 before lens fragment removal to 20/28 after surgical extraction.
The authors concluded that corneal edema is common in the setting of retained lens fragments, and it can lead to corneal decompensation requiring transplantation. Inferior corneal edema, in particular, should alert the ophthalmologist to possible retained lens fragments. Surgical removal of retained lens fragments should be considered at the time of diagnosis.
Chorioretinal Biopsy in the Diagnosis of Intraocular Lymphoma
December AJO
Mastropasqua et al. assessed the utility of chorioretinal biopsy in establishing a definitive diagnosis in intraocular lymphomas. They found that this type of biopsy was definitive in a majority of cases.
A retrospective, noncomparative diagnostic case series reviewing a 15-year period (1999-2014) was undertaken at Moorfields Eye Hospital. The study included 29 consecutive patients who presented with severe uveitis requiring an intraocular biopsy for suspected underlying lymphoma. The effectiveness of chorioretinal biopsy in establishing a definitive diagnosis or in excluding malignancy was determined. A specific histologic diagnosis of lymphoma was made in 17 cases (59%), while in 9 cases (31%), the biopsy combined with clinical data was effective in excluding malignancy. In the 3 remaining cases, no specific diagnosis was made. No intraoperative complications were reported. Postoperative complications, other than cataract, included 2 vitreous hemorrhages and 2 retinal detachments.
Of the 17 cases in which biopsy led to histologic diagnosis, 15 samples were obtained from eyes with marked vitritis, while 2 had minimal vitritis. The authors noted that the level of vitritis appears to be a strong index of likelihood for achieving a definitive histologic diagnosis.
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American Journal of Ophthalmology summaries are edited by Thomas J. Liesegang, MD.
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