Penetrating keratoplasty in children under 3 years old with congenital corneal opacities

AIM: To evaluate the graft rejection and visual outcomes after penetrating keratoplasty (PK) in the presence of various congenital corneal opacities in children. METHODS: In this retrospective cohort study, children who underwent PK were then followed for 5y. The patient's medical records were collected from June 2014 until June 2019 and analyzed in December 2019. All patients were children under three years old with congenital corneal opacities with or without microcornea who came to a pediatric ophthalmologist and underwent PK in Jakarta Eye Center (JEC). Beforehand, all children have participated in a thorough evaluation for PK. In the case of severe microcornea was not advised to undergo surgery. The visual outcomes and graft survival rate were described in percentages. The graft survival plot was presented with Kaplan-Meier, while the visual acuity was analyzed using the Wilcoxon signed ranks test. RESULTS: Sixteen eyes from eleven patients (seven girls and four boys) underwent PK. The graft survival rate of the first 6, 12, and 18 mo later of keratoplasty was 100%, 83.3%, and 66.7%, respectively. The overall mean survival time is 22mo (standard error 2.419), and no significant difference between the patients underwent PK before and after 36mo of their age (P=0.52). The graft failure was 50%, and post-surgery complications included cataract 43.7%, band keratopathy 12.5%, and scleromalasia 6.25%. Wilcoxon test analysis of visual acuity post keratoplasty was not statistically significant (P=0.34), while overall showed 44% improvements of visual outcome for 5y of follow-up. With a good survival at one year up to 22mo (83.3%), the visual acuity could be achieved (63%), and showed improvements (44%) during follow-up. CONCLUSION: The complications are frequent for pediatric PK. Thus, corneal surgery on infants requires careful case selection, adequate pre-operative evaluation, skilled surgery (optical correction), very close cooperation family–physician, intensive post-operation care, and amblyopia management in the future.

An Emerging, Neglected and Underestimated Zoonotic Parasitic Ocular Infestation: A Comprehensive Review on Thelaziasis

Human thelaziasis is an emerging insect-borne zoonotic ocular parasitic infestation, occur more commonly in rural communities with poor living and low socioeconomic living, and mainly affects the children and old age people, where humans live in close proximity with animals. Human thelaziasis is caused by both Thelazia callipaeda and Thelazia californiensis. T. callipaeda lives under the eye lids, nictitating membranes, orbit, conjunctival sac, lachrymal glands, and lacrimal ducts of cats, dogs, rabbits, horses, cattle, deer, badgers, monkeys, wolves, foxes (definitive hosts) and man being an accidental host. The vectors (intermediate hosts) are non-biting, tear-seeking, diptera flies of family Drosophilidae (fruit flies) Phortica variegata, which feeds on tears of their definitive hosts, including humans. Clinical manifestations include conjunctivitis, lacrimation, itching or pain with foreign body sensation, epiphora, follicular hypertrophy, and less often with severe signs and symptoms such as keratitis, photophobia, ectropion, corneal opacities (due to the migration of worm across the cornea), floaters within the eye chamber leading to visual impairment/blindness. The knowledge and scientific information on human thelaziasis is still unknown or relatively limited to many ophthalmologists and clinicians, and received little attention; hence this comprehensive and systematic review of human thelaziasis, is undertaken to highlight its importance and further research.

Study of State of Interface “Intraocular Lens — Posterior Capsule” Depending on Size of Capsulorhexis in Senile Cataract Phacoemulsification

Purpose. To study the state of interface “intraocular lens (IOL) — posterior capsule (PC)” depending on diameter of capsulorhexis in phacoemulsification of senile cataract.Patients and methods. 227 patients (227 eyes) were examined after phacoemulsification of senile cataract at LenSx femtosecond laser (Alcon, USA). The study did not include patients with corneal opacities, signs of axial displacement of lens, with irido- and phacodonesis, glaucoma, axial length less than 22 mm and more than 26 mm. Depending on diameter of performed capsulorhexis, we formed 3 groups: 1st group — 76 eyes with diameter capsulorexis 5.5 mm; 2nd group — 73 eyes with 5.0 mm; 3rd group — 78 eyes with 4.5 mm. We studied type of interface “IOL — PC”, the maximum value of PC diastasis and the maximum depth of its folds using an RTVue-100 Optical Coherence Tomography (Optovue, USA) on the first day after the operation.Results. The maximum number of eyes with absence of contact between IOL and PC was noted in the 3rd group (62.8 %), the largest number of eyes with full contact between IOL and PC (63.2 %) was in the 1st group. The minimum average depth of the PC folds (111.1 ± 32.7 μm) was noted in the 1st group, and the maximum (165 ± 75.4 μm) — in the 2nd group.Conclusion. The analysis showed that type of interface “IOL — PC” in the first day after phacoemulsification of senile cataract depends on diameter of capsulorhexis. The largest number of eyes (64.6 %) with full contact between IOL and PC was observed in the group of patients with capsulorhexis 5.5 mm, and the smallest (6.4 %) — in eyes with diameter capsulorexis 4.5 mm. Presumably, the main reason for the absence or incomplete contact between IOL and PC is the presence of viscous dispersive between them. The deformation of PC in the form of folds does not directly depend on diameter of capsulorhexis and, obviously, is due to the uneven tension of the capsular bag by the IOL haptics.

Understanding Immune Responses to Surgical Transplant Procedures in Stevens Johnsons Syndrome Patients

Stevens Johnsons syndrome (SJS) is a mucocutaneous disorder caused by an autoimmune response most commonly to medications. Unless it is properly managed in the acute setting, this entity can affect the ocular surface causing chronic cicatrizing conjunctivitis with limbal stem cell deficiency and lid anomalies which ultimately result in corneal opacities that may limit patients' visual acuity. When this stage is reached, some patients might need to undergo some form of corneal and/or limbal stem cell transplantation that exposes an already sensitized immune system to a new alloantigen. While the innate immunity plays a role in corneal graft survival, adaptive immune responses play a major part in corneal graft rejection and failure, namely through CD4+ T cell lymphocytes. Hence, the management of the immune response to surgical transplant procedures in SJS patients, involves a dual approach that modulates the inflammatory response to a new alloantigen in the context of an autoimmune sensitized patient. This review will explore and discuss current perspectives and future directions in the field of ocular immunology on how to manage SJS immune responses to ocular surgical procedures, reviewing systemic and local immunosuppressive therapies and protocols to adequately manage this debilitating condition.

Diagnosing Paraproteinemic Keratopathy: A Case Report

A 65-year-old man presented with bilateral, painless, progressive blurring of vision over 9 years. Slit-lamp examination revealed bilateral subepithelial corneal opacities in clusters located at the mid-periphery. Anterior segment optical coherence tomography, in vivo confocal microscopy (IVCM), serum protein electrophoresis, and molecular genetic testing were performed to evaluate the cause of corneal opacities. Anterior segment optical coherence tomography revealed a band-like, hyperreflective lesion in the Bowman layer and anterior stroma of both corneas. IVCM revealed hyperreflective deposits in the epithelium, anterior stroma, and endothelium. Serum protein electrophoresis identified the presence of paraproteins (immunoglobulin kappa), and molecular genetic testing revealed absence of mutations in the transforming growth factor beta-induced gene (<i>TGFBI</i>) and collagen type XVII alpha 1 gene (<i>COL17A1</i>). The ocular diagnosis of paraproteinemic keratopathy eventually led to a systemic diagnosis of monoclonal gammopathy of undetermined significance by our hematologist/oncologist. Paraproteinemic keratopathy is a rare differential diagnosis in patients with bilateral corneal opacities and therefore may be misdiagnosed as corneal dystrophy or neglected as scars. In patients with bilateral corneal opacities of unknown cause, serological examination, adjunct anterior segment imaging, and molecular genetic testing play a role in establishing the diagnosis.