RESUMEN
PURPOSE: To describe the incidence, characteristics, risk factors, treatment, and outcomes of ocular surface stem cell transplantation (OSST) rejection. METHODS: A chart review of patients who had OSST at a single institution between 1998 and 2010 was performed. Data were collected on patient demographics, type of OSST procedure, duration of immunosuppression, and rejection characteristics. Main outcome measures were ocular surface stability and improvement in best-corrected visual acuity. RESULTS: Two hundred twenty-two eyes of 158 patients were included with mean follow-up of 62.7 months (range, 12.0-158.3 months). The most common indications for OSST were aniridia (46.4%), chemical/thermal injury (22.1%), and Stevens-Johnson syndrome (12.2%). The most common procedures performed were keratolimbal allograft (KLAL) alone (80.6%) and combined living-related conjunctival allograft (lr-CLAL)-KLAL (11.3%). Mean time on immunosuppression was 44.3 months (range, 7.6-138.2 months). Severe rejection occurred in 43 eyes (19.4%) with mean time to rejection being 15.2 months (range, 0.2-93.1 months). Low-grade rejection occurred in 26 eyes (11.7%) with mean time to rejection being 26.2 months (range, 1.3-64.9 months). At the final follow-up, 36.6% of eyes in the rejection group achieved a stable ocular surface compared with 71.9% of eyes in the nonrejection group (P < 0.0001). Risk factors associated with increased risk of rejection were younger age (P < 0.0001), KLAL alone (P = 0.049), and noncompliance with immunosuppression (P = 0.047). CONCLUSIONS: Ocular surface outcomes for patients with OSST rejection are poor, with the majority of patients having failed ocular surfaces despite treatment with increased immunosuppression and repeat OSST. It is critical for success that OSST patients are closely monitored for rejection and for compliance with immunosuppression.
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Enfermedades de la Córnea/cirugía , Epitelio Corneal/trasplante , Rechazo de Injerto/epidemiología , Limbo de la Córnea/citología , Trasplante de Células Madre , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Niño , Femenino , Estudios de Seguimiento , Rechazo de Injerto/diagnóstico , Rechazo de Injerto/prevención & control , Humanos , Inmunosupresores/uso terapéutico , Incidencia , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Riesgo , Células Madre , Factores de Tiempo , Trasplante Homólogo , Resultado del Tratamiento , Adulto JovenRESUMEN
PURPOSE: To describe the technique and present the outcomes of combined conjunctival limbal autografts (CLAU) and keratolimbal allografts (KLAL) for the treatment of unilateral severe ocular surface failure. METHODS: Interventional case series. Eleven eyes of 11 patients who sustained chemical burns (4 alkali and 2 acid) and combined chemical/thermal burns (5 eyes) from firework explosions had combined CLAU/KLAL surgery. Keratoplasty was performed subsequently for residual corneal stromal scarring limiting visual acuity. Inclusion criteria included eyes with severe unilateral total ocular surface failure, controlled glaucoma, and reasonable eyelid apposition with no exposure. Exclusion criteria included patients with any ocular surface abnormality in the fellow eye and those with contraindications to systemic immunosuppression (SI). Outcome measures included Snellen best-corrected visual acuity (BCVA), ocular surface stability, SI exposure, and complications. RESULTS: Preoperative BCVA was 20/400 or worse in all eyes. At the final follow-up (mean, 35.8 months; range, 12.1-105.9 months), 73% (8 of 11) eyes had BCVA of 20/80 or better (range, 20/25 to counting fingers), and ocular surface was stable in 82% (9 of 11). Ninety-one percent (10 of 11) had additional penetrating keratoplasty (PK) with a 60% (6 of 10 eyes) success rate. Three cases had subsequent Boston type 1 keratoprosthesis implantation after PK failure, and the fourth patient, at the time of his last follow-up visit, did not want further intervention for his edematous PK, which was a result of noncompliance-related corneal rejection. In eyes with more than 2 years of follow-up, SI was tapered at a mean of 16 months (range, 8-28 months). There were no intraoperative complications. No secondary tumors, cardiac events, or deaths occurred while patients were on SI. One patient developed secondary glaucoma refractory to medical management after subsequent PK, requiring cyclodiode laser. CONCLUSIONS: Combined CLAU/KLAL and staged keratoplasty is effective in improving vision and maintaining long-term ocular surface stability in patients with severe unilateral ocular surface disease and conjunctival deficiency.
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Traumatismos por Explosión/cirugía , Quemaduras Químicas/cirugía , Conjuntiva/trasplante , Enfermedades de la Córnea/cirugía , Quemaduras Oculares/inducido químicamente , Limbo de la Córnea/citología , Trasplante de Células Madre , Adolescente , Adulto , Anciano , Traumatismos por Explosión/fisiopatología , Quemaduras Químicas/fisiopatología , Terapia Combinada , Enfermedades de la Córnea/fisiopatología , Combinación de Medicamentos , Epitelio Corneal/citología , Femenino , Glucocorticoides/administración & dosificación , Humanos , Inmunosupresores/administración & dosificación , Queratoplastia Penetrante , Masculino , Persona de Mediana Edad , Implantación de Prótesis , Sulfametizol/administración & dosificación , Donantes de Tejidos , Trasplante Autólogo , Trasplante Homólogo , Trimetoprim/administración & dosificación , Agudeza Visual/fisiología , Adulto JovenRESUMEN
PURPOSE: To describe the systemic immunosuppression protocol used at the Cincinnati Eye Institute and University of Cincinnati, and to evaluate the success, tolerability, and side effects of systemic immunosuppression in patients undergoing ocular surface stem cell transplantation (OSST). METHODS: Retrospective study of all patients who had OSST from 1997 to 2007 and received follow-up for systemic immunosuppression at the Cincinnati Eye Institute. Patients were analyzed for demographics, systemic immunosuppression exposure, ocular surface stability, efficacy, and toxicity variables. RESULTS: A total of 225 eyes from 136 patients with a mean age of 43.6 years (range, 8.9-80.6 years) underwent OSST with systemic immunosuppression. The most common systemic immunosuppression regimen consisted of tacrolimus, mycophenolate mofetil, and a short course (1-3 months) of prednisone (102/136 patients, 75%). Prophylactic valganciclovir and trimethoprim/sulfamethoxazole (dapsone if sulfa allergy was present) were also used. Mean duration of immunosuppression was 42.1 months (range, 3.6-128 months) and mean follow-up time after OSST was 53.9 months (range, 3.6-147.3 months). At the patients' final follow-up visit, 105/136 patients (77.2%) had a stable ocular surface. There were 3 severe adverse events in 2 patients (1.5%) and 21 minor adverse events in 19 patients (14.0%). Of the 21 patients with adverse events, 10 (47.6%) had systemic comorbidities at initial presentation. CONCLUSIONS: The prevention of graft rejection with the use of systemic immunosuppression after OSST is crucial and should be approached with the same rigor as in solid organ transplantation. With appropriate long-term monitoring by the cornea specialist and transplant physician, the risk of irreversible toxicity at current dosages of systemic immunosuppression in this population is minimal.
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Enfermedades de la Córnea/terapia , Epitelio Corneal/trasplante , Rechazo de Injerto/prevención & control , Terapia de Inmunosupresión , Inmunosupresores/uso terapéutico , Limbo de la Córnea/citología , Trasplante de Células Madre , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Niño , Quimioterapia Combinada , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Ácido Micofenólico/análogos & derivados , Ácido Micofenólico/uso terapéutico , Prednisona/uso terapéutico , Estudios Retrospectivos , Tacrolimus/uso terapéutico , Factores de Tiempo , Adulto JovenRESUMEN
PURPOSE: To explain our preferred technique and evaluate the success of ocular surface transplantation using a combined living-related conjunctival limbal allograft (lr-CLAL) and keratolimbal allograft (KLAL) in patients with severe ocular surface failure and conjunctival deficiency. METHODS: Retrospective study of all patients undergoing combined lr-CLAL/KLAL at the Cincinnati Eye Institute/University of Cincinnati. Patients were retrospectively analyzed for demographics, immunosuppression exposure, ocular surface stability, and need for keratoplasty. Snellen best-corrected visual acuity was evaluated preoperatively and at final visit. RESULTS: Nineteen patients (24 eyes) underwent combined lr-CLAL/KLAL. Mean follow-up was 43.4 months (range: 12.2 to 125.5 months). At the last recorded visit, the ocular surface was stable in 54.2% (13 of 24), improved in 33.3% (8 of 24), and failed in 12.5% (3 of 24) of eyes. 79.2% (19 of 24) of patients underwent staged keratoplasty. For the primary keratoplasty, 73.7% (14 of 19) of patients underwent penetrating keratoplasty, 21.1% of patients underwent Boston type I keratoprosthesis, and 5.2% of patients underwent deep anterior lamellar keratoplasty; 57.9% of patients required repeat keratoplasty. Preoperative best-corrected visual acuity was 20/400 or worse in 87.5% (21 of 24); 75% (18 of 24) of eyes had improvement in visual acuity at the last follow-up with 70.8% of patients (17 of 24) achieving 20/125 vision or better. Of patients with a Boston keratoprosthesis, 90.0% (9 of 10) had an improvement in vision with 70.0% achieving 20/125 vision or better at the last follow-up. CONCLUSIONS: Ocular surface transplantation with a combined lr-CLAL/KLAL and staged keratoplasty is an effective procedure to improve visual acuity in patients with severe ocular surface disease and conjunctival deficiency. Keratoprosthesis after limbal stem cell transplantation is an alternative to penetrating or lamellar keratoplasty in this patient population.
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Conjuntiva/trasplante , Enfermedades de la Córnea/cirugía , Células Epiteliales/trasplante , Limbo de la Córnea/citología , Procedimientos Quirúrgicos Oftalmológicos , Trasplante de Células Madre , Femenino , Estudios de Seguimiento , Humanos , Donadores Vivos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Trasplante Homólogo , Resultado del Tratamiento , Agudeza Visual/fisiologíaRESUMEN
PURPOSE: 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). METHODS: 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. RESULTS: 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. CONCLUSIONS: Thin EK versus thick EK, as measured by AS-OCT in the postoperative period, showed a statistically significant improvement in BSCVA.
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Queratoplastia Endotelial de la Lámina Limitante Posterior , Endotelio Corneal/patología , Donantes de Tejidos , Agudeza Visual/fisiología , Anciano , Edema Corneal/cirugía , Endotelio Corneal/trasplante , Bancos de Ojos , Femenino , Estudios de Seguimiento , Distrofia Endotelial de Fuchs/cirugía , Humanos , Queratoplastia Penetrante , Masculino , Estudios Retrospectivos , Tomografía de Coherencia ÓpticaAsunto(s)
Enfermedades de la Córnea/etiología , Epitelio Corneal/patología , Trasplante de Células Madre , Células Madre/patología , Enfermedades de la Córnea/diagnóstico , Enfermedades de la Córnea/cirugía , Epitelio Corneal/trasplante , Humanos , Limbo de la Córnea/patología , Limbo de la Córnea/cirugía , Pronóstico , Índice de Severidad de la EnfermedadRESUMEN
PURPOSE: To determine and compare the incidence of posterior capsule opacification (PCO) and neodymium:YAG (Nd:YAG) laser capsulotomy after implantation of 3 intraocular lens types (IOLs). SETTING: Storm Eye Institute, Medical University of South Carolina, Charleston, South Carolina, USA. METHODS: This retrospective chart review comprised eyes having uneventful phacoemulsification and implantation of 1 of 3 AcrySof IOLs: ReSTOR SN60D3 (multifocal spherical group), Natural SN60AT (monofocal spherical group), or IQ SN60WF (monofocal aspheric group). Eyes were matched by age, sex, and follow-up. The PCO rate, Nd:YAG capsulotomy rate, time from surgery to PCO diagnosis, and time from surgery to Nd:YAG capsulotomy were assessed. RESULTS: Charts of 225 eyes (75 in each group) with a mean follow-up of 15.9 months +/- 6.5 (SD) were evaluated. The PCO rate was 42.7% in the multifocal spherical group, 28.0% in the monofocal spherical group, and 14.7% in the monofocal aspheric group. The Nd:YAG capsulotomy rate was 25.3%, 17.3%, and 4.0%, respectively. The difference in the Nd:YAG rate was statistically significantly higher in the multifocal and monofocal spherical groups than in the monofocal aspheric group (P<.001 and P<.008, respectively) but was not significantly different between the 2 spherical IOL groups (P = .232). The time from surgery to PCO documentation was not significantly different between the 3 groups. CONCLUSIONS: Intraocular lens configuration may have contributed to the difference in the PCO rate between the 2 spherical IOLs and the aspheric IOL. Based on the Nd:YAG rate as an indicator for visual significance, PCO may be less visually significant in eyes with the aspheric IOL than in eyes with 1 of the spherical IOLs.
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Catarata/etiología , Cápsula del Cristalino/patología , Lentes Intraoculares , Facoemulsificación , Complicaciones Posoperatorias , Agudeza Visual/fisiología , Adulto , Anciano , Anciano de 80 o más Años , Catarata/terapia , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Terapia por Láser , Láseres de Estado Sólido/uso terapéutico , Cápsula del Cristalino/cirugía , Implantación de Lentes Intraoculares , Masculino , Persona de Mediana Edad , Seudofaquia/fisiopatología , Estudios RetrospectivosRESUMEN
PURPOSE: To analyze the patient reported outcome of satisfaction after LASIK surgery. DESIGN: Systematic review. PARTICIPANTS: Patient data from previously reported studies. METHODS: A literature search conducted for the years 1988 to 2008 that included pertinent LASIK surgery information from the review of 2915 retrieved citations. All abstracts from these citations were reviewed and 1581 were deemed to be relevant for review. Complete copies of each of these relevant (1581) articles were obtained, and after thorough analysis each was rated based on the strength of the study design and weight of evidence. A level I rating was assigned to properly conducted, well-designed, randomized clinical trials; a level II rating to well-designed cohort and case-control studies; and a level III rating to case series, case reports, and poorly designed prospective and retrospective studies. Level I and II rated, peer-reviewed articles were entered into a database, and level III articles were eliminated. A total of 309 articles were incorporated into this database, representing level I and level II well-controlled studies of primary LASIK surgery. MAIN OUTCOME MEASURES: Patients' satisfaction rates and factors associated with dissatisfaction. RESULTS: Nineteen of the 309 database articles (6.1%) reported on both patient quality of life and satisfaction and together encompassed a total of 2198 subjects. The procedures from these 19 articles took place between 1995 and 2003. The overall patient satisfaction rate after primary LASIK surgery was 95.4% (2097 of 2198 subjects; range of patient satisfaction for the 19 articles was 87.2%-100%). The patient satisfaction rate after myopic LASIK was 95.3% (1811 of 1901 patients), and after hyperopic LASIK was 96.3% (286 of 297 subjects). CONCLUSIONS: Based on this review, worldwide, an average 95.4% of patients were satisfied with their outcome after LASIK surgery. With 16.3 million procedures performed worldwide, and more than a decade of clinical studies and technological innovation, LASIK surgery should be considered among the most successful elective procedures. LASIK surgery compares more favorably with other elective surgical procedures in terms of generally higher satisfaction rates.
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Hiperopía/cirugía , Queratomileusis por Láser In Situ , Miopía/cirugía , Satisfacción del Paciente/estadística & datos numéricos , Calidad de Vida , Adolescente , Adulto , Anciano , Bibliometría , Salud Global , Humanos , Persona de Mediana Edad , Resultado del TratamientoRESUMEN
PURPOSE: Susceptibility to herpes stromal keratitis (HSK) is strongly influenced by genetic factors, as shown by multiple rodent models using human herpes simplex virus. A single gene, encoding the immunoglobulin G (IgG) 2a heavy chain protein, confers susceptibility or resistance through a mechanism involving molecular mimicry in one mouse model. However, other rodent studies have produced contradictory results. This study tested the hypothesis that the GM23 gene (the human IgG2a homolog) influences susceptibility to HSK in humans. METHODS: The study population consisted of all consenting patients diagnosed with HSK (25 whites, 2 African Americans) at the Medical University of South Carolina Storm Eye Institute Clinic in Charleston, SC, between August 2000 and June 2004. Healthy controls (23 white adults with no history of HSK) were recruited from the same local population. Genomic DNA from subjects was genotyped at the GM23 locus, which has been implicated as an HSK resistance gene in animal models, by polymerase chain reaction-restriction fragment length polymorphism (RFLP) analysis. RESULTS: No difference in GM23 genotype frequency was observed between patients with HSK and controls. CONCLUSION: Susceptibility to HSK in whites is not predicted by GM23 genotype.