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La greffe de membrane amniotique est une technique desormais adoptee par tous dans la prise en charge des pathologies de la surface oculaire. Suivant les indications, la membrane amniotique est utilisee en greffe ou en patch. Dans le premier cas, la membrane amniotique sert de substrat a la repousse epitheliale deficiente et le chirurgien vise l’integration de la membrane amniotique. Sa membrane basale permet en effet de renforcer l’adhesion et la differentiation des cellules epitheliales de la cornee, de faciliter leur migration et de prevenir leur apoptose. Dans le deuxieme cas (patch), la membrane amniotique est suturee epithelium vers le bas de facon a delivrer les facteurs biologiques dont elle est impregnee en concentration maximale : elle recouvre la cornee pathologique en jouant a la fois un role de pansement biologique et egalement un role antalgique. Les meilleures indications des greffes de membrane amniotique sont les brulures chimiques au stade aigu et les ulceres corneens trophiques refractaires a tout traitement medical. Lorsque ces derniers sont perforants ou preperforants, la greffe amniotique est realisee au mieux en multicouches de facon a permettre la restauration d’une certaine epaisseur corneenne. En cas de deficit limbique avere, la membrane amniotique peut etre un complement interessant aux techniques de greffes de cellules souches limbiques desormais necessaires. A l’avenir, la membrane amniotique sera le support indispensable des expansions de cellules souches cultivees. La greffe de membrane amniotique peut egalement etre proposee pour reconstruire la conjonctive lors de la chirurgie d’exerese des symblepharons ou des tumeurs conjonctivales. Son utilisation isolee n’est alors limitee qu’aux pathologies peu inflammatoires et sans fibrose extensive.

But de l’etude La prise en charge des perforations corneennes non traumatiques reste difficile. Nous avons mene une etude retrospective afin d’en recenser les etiologies et de rapporter l’efficacite des differentes techniques chirurgicales. Patients et methodes Notre serie comprend 56 patients hospitalises entre 1997 et 2004 pour une perforation corneenne non traumatique. L’âge moyen des patients etait de 69 ans (16 a 95 ans), le suivi moyen de 20,5 mois (6 a 96 mois). Resultats Les causes de perforation corneenne ont ete un ulcere trophique dans 24 cas (43 %), un ulcere inflammatoire peripherique dans 10 cas (18 %), une perforation corneenne sur syndrome sec dans 6 cas (11 %), un abces infectieux perforant dans 7 cas (13 %). Tous les patients ont eu un traitement medical specifique adapte avant d’envisager la chirurgie. En premiere intention, la colle cyanoacrylate a ete utilisee dans 14 cas (50 % de succes anatomique), une greffe amniotique en multicouches dans 23 cas (100 % de succes anatomique), un recouvrement conjonctival dans 6 cas, une greffe lamellaire peripherique dans 3 cas (33 % de succes anatomique), une greffe transfixiante « a chaud » dans 13 cas (31 % de succes anatomique) et un patient a du etre eviscere. Plusieurs interventions ont ete necessaires dans 16 cas (28 %), neuf patients ayant au final un recouvrement conjonctival. L’integrite du globe a pu etre maintenue dans 91 % des cas et 32 % des yeux ont recupere une acuite visuelle chiffrable entre 1/20 e et 4/10 e . Conclusion Les perforations corneennes non traumatiques sont souvent de mauvais pronostic visuel malgre une prise en charge rapide. La greffe amniotique en multicouches est un outil chirurgical tres efficace lorsque la perforation est d’origine trophique. Nous recommandons la realisation d’un recouvrement conjonctival en cas de recidive de la perforation.

Aims: In many countries the number of corneal donations is far too low to graft all patients on waiting lists within reasonable time. The aim of this study was to define specifically what practical changes are to be implemented to fully meet corneal graft demand. Methods: The list of potential donors drawn by the coordination team from 1 January to 31 December 1999 was compared with that of all patients who had died during the same period. In each identified record, the parameters which permitted or precluded effective collection of cornea specimens were analysed, and the reasons why other records were not identified were investigated. Results: Among the 1112 patients who died in 1999, coordinating nurses were able to identify 451 records (40.5 %) including 329 patients aged between 18 and 85 years (29.5%). After excluding 184 patients (55.9 %) who presented with medical contraindications, the coordinating nurses were able to meet the relatives of only 55 out of 145 patients (38%) and obtained their agreement in 39 cases (71% approval rate). Therefore, relatives' refusal was the cause for the absence of collection in only 5.5% of cases (16/290). The number of cornea procurements amounted to 11.8% of identified records and 3.5% of all deceased patients. Conclusion: French law and regulations regarding tissue collection are based on consent presumption but it requires that verifications be made with the relatives to ensure that potential donors were not, before their death, opposed to such tissue procurement. That provision implies a high degree of organisation on the part of coordinating teams. It was demonstrated that donation shortage is no longer the result of relatives' refusal but rather because of logistical difficulties (potential donors not identified and problems in reaching relatives). It appears necessary therefore to strengthen coordinating teams with sufficient staff levels for wider donor identification. Those teams should also find ways to keep closer contact with relatives, so as to meet the maximum transparency targets required by public opinion and regulations and to graft all patients awaiting corneal transplantation.

Purpose This study compares two techniques of preparation of the endothelial graft: the DSAEK (Descemet Stripping Automated Endothelial Keratoplasty) and an ultrathin endothelial graft manually prepared. Methods A randomised prospective study is being conducted at the Hospital of Rouen, France. Patients presenting a Fuchs dystrophy are included in two groups. Patients from Group A receive an ultrathin manually prepared endothelial graft and patients from Group B receive a DSAEK. In order to improve the power of our study, one patient from each group is grafted on the same day, with a corneal endothelium coming from the same donor. Improvement of visual acuity is the main outcome measure. Vitality of the graft, refractive modifications induced by surgery and complications are also studied. Results Currently, 22 patients with a follow up of 6 months have been included. At inclusion, patients from Group A and B were not statistically different. Six months after surgery, mean best corrected visual acuity has significantly improved in both groups but is statistically better in Group A (0,18 logMar in Group A versus 0,31 logMar in Group B (p

Purpose The DMEK is the only technique for endothelial graft without interface. It is however difficult to perform, especially the preparation of the graft. We present in this study a new simple device facilitating the preparation of grafts for DMEK. Methods The device, named “Muraine Punch” is a circular trephine with a blade which was open in two places and a guard to 300 micronmeters deep. The blade was pressed against the endothelial surface so as to sever Descemet's membrane and cut part of stroma. The preparation of descemetic graft was then continued on an artificial anterior chamber using a 27 gauge cannula , reversed upwardly corneal endothelium. Three methods of assessing injury of endothelial cells (ECs) were then performed: 1 / conventional measurement of the endothelial cell density (ECD). 2 / laboratory measurement of the viable ECD by image analysis after staining of ECs by alizarin red, followed an counterstaining using Dioc 6 (cytoplasm) and Hoechst (nucleus). 3/ post operatory ECD of 47 patients. Results Histological analysis confirmed this “Muraine technique” offered a pure Descemet membrane grafts for DMEK. The ECD analysis showed consistent with that of the grafts for transfixant keratoplasty. Conclusion The new technique with “Muraine Punch” facilitates the preparation of grafts for DMEK and causes only a minimal cell loss. Commercial interest

Purpose Descemet’s membrane and endothelial keratoplasty (DMEK) is the only technique to achieve a posterior corneal transplant without any interface. It is however difficult to achieve, mainly during the preparation of the graft. We propose a simple novel surgical device to facilitate this preparation. Methods We used 20 corneas for research in this study. The device is in the form of a circular blade with a diameter of 8.5 mm. The blade is broken in two opposite points on 4 mm. The blade is applied to the cornea in order to cut Descemet's membrane and deep stroma. Preparation of the endothelial graft is performed on an artificial anterior chamber using a simple technique with a 27 gauge cannula to detach Descemet’s membrane. The dissection is performed under the microscope by a corneal bank technician in 8 cases, by a resident in 4 cases by a cataract surgeon in 8 cases. The three operators followed a specific course on the same day of dissection but had never tried to dissect a DMEK graft before. Endothelial cell density (ECD) was measured before dissection and 3 days after storage in organ culture. Histological analysis was performed. Results Descemet graft could be easily dissected in 19 cases and resident failed dissection in one case. ECD was 2534±275 cells/mm² before dissection and 2412+/-360 cells/mm², after 3 days in organ culture (p

Purpose To assess the viable endothelial cell density (vECD) of posterior lamellar grafts, stored in organ culture, precut by eye bank technicians, and sent to a distant center. Methods Paired corneas with an ECD >2200 cells/mm2 at the standard assessment with the SambaCornea analyser (TribVn, France), were stored in CorneaMax (Eurobio, France) and deswelled in CorneaJet (5% Dextran T500) for 6 to 24 hours prior to pre-cutting. They were randomly assigned as full-thickness grafts or as precut posterior transplants for DSAEK using a microkeratome with a 350μm head (Moria, France). Corneas were sent to a distant center where the vECD was assessed by using the triple Hoechst/Ethidium/Calcein (HEC) staining and fluorescent image analysis of the entire posterior surface: calculation of the area covered by living cells (H+/C+/E-) coupled with counting of nuclei in large areas allowed to determine the vECD, i.e. the useful cell pool (Pipparelli. IOVS 2011.52:6018). DSAEK and controls data were compared with non-parametric tests. Results In both groups, the vECD was lower than the standard ECD determined by the eye bank (for 20±7% for full thickness grafts, 34±16% for DSAEK), because living cells never completely covered the entire posterior surface. vECD were respectively of 2006+/-349 vs 1661+/-464 (P=0.075). Conclusion The HEC triple staining combined with image analysis provides a unique accurate assessment of the endothelial quality by giving the vECD. This laboratory technique allows a reliable assessment of the endothelial quality of tissues supplied to surgeons, precut or not. It can also be used to assess any methods liable to modify EC.

Purpose: To report results of two surgical procedures of endothelial keratoplasty Methods: Prospective, noncomparative study. Thirty height eyes of 38 patients with 21 corneal edema Fuchs dystrophy, 11 pseudophakia dystrophy, 4 decompensation of penetrating graft and 2 corneal edema after herpes endothelitis In all eyes, the recipient Descemet membrane was excised using descemetorhexis through a 3.2 mm corneal incision. In 17 cases endothelial transplant was harvested by lamellar manual dissection. In 21 cases separation of endothelium was made performed with viscoelastic dissection. A temporary gas bubble was used for donor tissue adherence. Preoperative and postoperative best spectacle-corrected visual acuity (BCVA), manifest refraction, astigmatism, pachymetry and endothelial cell density (ECD) were evaluated 2 and 6 months after surgery. Results: At the end of follow-up 37 grafts remained transparent and grafts were healed in good position. One eye required conversion to standard penetrating keratoplasty. At 2 months, BSCVA in the group of Fuchs dystrophy is 20/40 and 20/25 at 6 months. In the group of pseudophakia keratopathy BSCVA is 20 /100 and 20/63 at 2 and 6 months respectively. The average MR astigmatism was 1.3 D. The mean pachymetry is stable after 1 month at 540 mm . The average ECD at 2 months was 1500 cells/mm2 and 1300 cells/mm2 at 6 months. Conclusions: This procedure, with its absence of corneal surface incisions and sutures, is a safe procedure that preserves the normal corneal topography, minimizes astigmatism and corneal power changes. This technique offers considerable advantages over penetrating keratoplasty in the treatment of endothelial dysfunction.

Amniotic membrane transplantation is now a widely adopted technique in the field of eye surface diseases. Depending on the indication, the amniotic membrane can be used as either a graft or a patch. When used as a graft, the amniotic membrane serves as a substrate for regrowth of deficient epithelium; the aim is to integrate this membrane. The basal membrane reinforces the adhesion and differentiation of the corneal epithelial cells, facilitates their migration, and prevents their apoptosis. When used as a patch, the amniotic membrane is sutured epithelium-down so as to maximize the concentration of biological factors delivered by this membrane: the membrane covers the diseased cornea and acts as a biological bandage and analgesic. The best indications for amniotic membrane grafts are acute chemical burns and trophic corneal ulcers refractory to all medical treatment. When these ulcers are perforated or in the early stages of perforation, it is best to use multiple layers of amniotic membrane, restoring the thickness of the cornea. In cases of confirmed limbal deficiency, amniotic membrane grafts may be a useful complement to the necessary limbal stem cell grafts. In the future, amniotic membranes will provide an indispensable support for the expansion of cultured stem cells. Amniotic membrane grafts may also be used to reconstruct the conjunctiva following the exeresis of symblepharons or conjunctival tumors. However, the use of this technique is currently limited to diseases with little inflammation and no extensive fibrosis.

Treatment of nontraumatic corneal perforation is a difficult task. The aim of our study was to retrospectively analyze predisposing conditions leading to perforation, surgical treatments, and visual outcomes.Fifty-six patients were admitted in our department for a nontraumatic corneal perforation between 1997 and 2004. Mean patient age was 69 years (range, 16-95 years) and the mean follow-up was 20.5 months (range, 6-96 months).The diseases associated with perforations were neurotrophic ulcer in 24 cases (43%), peripheral immunologic ulcer in ten cases (18%), dry eye in six cases (11%), and infectious keratitis in seven cases (13%). All patients had specific adapted medical treatment before surgery. As a first procedure, we used cyanoacrylate glue in 14 cases (50% anatomic success), multilayer amniotic membrane transplantation in 23 cases (100% anatomic success), conjunctival flap in six cases, peripheral lamellar graft in three cases (33% anatomic success), emergency penetrating keratoplasty in 13 cases (31% anatomic success), and one patient's eye had to be eviscerated. Several surgical procedures were necessary in 16 cases (28%), nine patients needing total conjunctival flap at the end. We were able to achieve tectonic stability in 91% of eyes and 32% of patients recovered useful visual acuity between 20/400 and 20/50.Amniotic membrane transplantation is an effective method for managing corneal perforations and usually does not need a further reconstructive procedure. Visual outcome is poor when peripheral or central keratoplasty are needed. We recommend a conjunctival flap when descemetocele or perforation recurs despite previous surgical management.

Amniotic membrane's unique combination of properties including the facilitation of migration of epithelial cells, the reinforcement of basal cellular adhesion and the encouragement of epithelial differentiation [6] together with its ability to modulate stromal scarring and its anti-inflammatory and anti-bacterial activity has led to its use in the treatment of ocular surface pathology as well as an adjunct to stem cell grafts of the corneal limbus [6-4]. We report a prospective study of 30 patients so treated.We studied 31 eyes of 30 patients subjected to amniotic membrane grafts between September 1999 and May 2000. There were 25 men and 5 women with an average age of 60.1 (range 25-86) years who were followed for a mean of 7.7 (range 4-11) months. 5 groups (A to D) were observed: A: 6 eyes. Small chronic ulcers without limbal involvement. B: 4 eyes. Ulcers of at least 75% corneal area or occupying 75% of the limbus. C: 9 eyes. Corneal burns. D: 8 eyes. Painful bullous corneal dystrophies unresponsive to other treatment. E: 4 eyes. Symblepharons. Amniotic membrane was placed on the corneal lesion, epithelial surface externally [6, 15], trimmed and sutured with interrupted 10/0 nylon, removed at one month. In two patients (11, 12) inflamed conjunctiva was recessed and amnion sutured to the recessed margin. For the bullous dystrophies we removed all the corneal epithelium and either sutured the amnion to peri-limbal conjunctiva (4 eyes) or to the limbus (4 eyes). For the symblepharons the conjunctiva was dissected to reform the fornix which was lined with amniotic membrane, sutured with 8/0 vicryl. Patients were reviewed regularity.Group A: All healed within 15 days, in most with dissolution of the amnion over 2-3 months although some persisted, covered with corneal epithelium. An eye with a Descemetocoele and one with a microperforation both healed. Vision improved more than two lines in 4 of 6 eyes. Group B: 2 of 4 eyes healed, one despite detachment of the membrane after 15 days. One eye was salvaged by tarsorrhaphy over a fresh keratoplasty after perforation of a neuroparalytic ulcer on failure of three successive amnion grafts. The final cornea vascularised despite an amnion graft for a meta-herpetic ulcer. Group C: 2 of 9 eyes had limbal damage in one quadrant but 7 had vessels in at least three-quarters of the circumference. One (15) also had a limbal autograft. 3 of 9 eyes healed satisfactorily with more than 2/10 improvement in acuity in each case. 2 showed further neovascularisation despite surface healing. One old chemical burn healed satisfactorily but vascularisation remained 5 eyes failed to heal with lysis of the graft, the patient who had a limbal autograft developed a vascular pannus, and in 4 eyes neovascularisation progressed to cover the entire cornea. Group D: 3 eyes settled with loss of symptoms but in 5 the graft detached within 15 days. All eyes where the membrane had been sutured to the conjunctiva beyond the limbus failed whilst 3 of 4 in which it had been sutured anterior to the limbus succeeded, leaving a persistent whitish membrane under the epithelium. Group E: We were able to reconstruct the cul de sac in 3 out of 4 eyes. In one patient with recurrent pterygium good ocular movement was restored, previously limited by scarring. One with associated ocular surface damage from a thermal burn failed by scarring of the cul de sac a month after surgery.Our best results were in persistent trophic ulcers of the cornea (Groups A and B) with a success rate of 80%, comparable to those of others [49, 37, 38]. The ready availability of amniotic membrane in our facility makes amniotic membrane transplantation the main secondary treatment for such lesions, especially because of the visual improvement we obtained. Because we did not observe any improvement in corneal thickness after this treatment we advise its early use before significant stromal lysis. The technique was not sufficient to control the effect of corneal anaesthesia in two eyes [40] or in chemical burns suggesting that amniotic membrane alone is insufficient to promote corneal healing in the absence of limbal stem cells. Nevertheless, three eyes did benefit. It has been suggested [13] that the anti-apoptotic function of amnion may prevent stem cell loss in such eyes [42], thus it appears logical to offer an amniotic membrane graft first, before stem cell transplantation, which may entrain complications in the donor eye if autografted [43] or because of the rejection risk of an allograft. It may be that an amniotic membrane graft simply becomes a holding procedure allowing time to settle the eye so as to allow secondary procedures to address the underlying cause of further damage. Our treatment of bullous dystrophy only succeeded on confining the graft to within the limbus, 3 out of 4 eyes becoming comfortable. By contrast we found amniotic membrane helpful in reconstructing symblepharons in the absence of local inflammation.Amniotic membrane grafting is a simple and straightforward surgical technique which should form part of the therapeutic arsenal for the treatment of ocular surface disease. Indications for the technique need further clarification for it is evident that it cannot correct all secondary pathology associated with limbal destruction. It is certainly preferable to conjunctival advancement and has proved useful in the reconstruction of the cul-de-sac.

Introduction La preparation du greffon endothelial est probablement l’etape la plus difficile lors de la greffe endotheliale. L’objectif de cette etude est de valider la faisabilite de la preparation et de l’envoi des greffons endotheliaux par les banques de cornees vers les sites greffeurs. Materiels et Methodes Dix cornees experimentales, maintenues en organoculture depuis 7 a 10 jours, ont ete utilisees au cours d’une premiere experience. La dissection du greffon endothelial a ete realisee sur une chambre anterieure artificielle. L’endothelio-descemet a ete separe du stroma a l’aide d’une spatule puis isolee aux ciseaux sur 350° avant remise en culture a 31 °C. La densite cellulaire endotheliale (DCE) a ete mesuree apres coloration au bleu trypan avant dissection et 48 heures apres. Cinq paires de cornees ont ete utilisees au cours de la deuxieme phase. Pour chaque paire, une cornee a beneficie d’une dissection endotheliale tandis que l’autre a servi de temoin. Les deux cornees ont ete adressees dans les 48 heures par transporteur vers un laboratoire collaborateur distant de 600 km. Les cornees ont beneficie alors d’une nouvelle mesure de la DCE puis d’une evaluation de la mortalite et de la viabilite cellulaire par triple coloration Hoechst/Ethidium homidimere/Calceine. Resultats Le greffon endothelial restait bien plaque au stroma dans tous les cas pendant sa conservation et son transport. Il se detachait ensuite facilement par simple section de la charniere laissee en place. La DCE moyenne etait de 2 767 cellules/mm2 (de 2 434 a 2 984) avant decoupe endotheliale et passait a 2 687 cellules/mm2 (de 2 419 a 2 982) apres 48 h, ce qui represente une perte cellulaire de 3 % (mediane = 1 %). La perte maximale sur cette serie etait de 15 %. Le pourcentage de cellules mortes etait inferieur a 1 % dans tous les cas apres decoupe. La triple coloration HEC confirmait la bonne viabilite endotheliale apres transport. Discussion Il est possible d’envisager larealisation d’une serie clinique de greffes endotheliales avec des greffons predecoupes, lors d’un protocole valide. Conclusion Nos travaux confirment la possibilite de preparer a l’avance les greffons endotheliaux en vue de leur greffe. Ceci devrait permettre une meilleure diffusion de cette technique dont les avantages ne sont plus a demontrer.

Objectif Rapporter les resultats d’une technique originale de greffe endothelio-descemetique chez les patients atteints d’une cornea guttata evoluee et analyser la perte endotheliale en fonction de la courbe d’apprentissage. Materiels et Methodes Il s’agit d’une etude de cas, prospective, non comparative realisee chez 33 patients porteurs d’une dystrophie primitive de Fuchs evoluee et operes d’une greffe endothelio-descemetique. Notre serie comprend 24 femmes et 9 hommes d’une moyenne d’âge de 68 ans (45 – 89 ans). Le groupe A comprend 20 patients operes consecutivement entre janvier et juin 2006. Le groupe B comprend 13 patients operes consecutivement entre janvier et mai 2007. Un descemetorhexis permet le retrait de la membrane de Descemet du receveur au travers d’une incision de 3,2 mm. Le greffon descemetique est preleve sur une chambre anterieure artificielle a l’aide d’une spatule. Il est ensuite enroule sur lui-meme dans une cartouche a injection puis extrait et deplie a l’aiguille dans la chambre anterieure. Suivant les cas, une bulle d’air ou de gaz est laissee en fin d’intervention. L’acuite visuelle, la refraction, la pachymetrie et la densite endotheliale ont ete evaluees a 1, 2 mois puis 6 mois apres l’intervention. Resultats Tous les greffons sont restes viables au terme du suivi. Les 2 groupes ne presentent pas de difference significative en termes d’acuite visuelle ou de refraction. La recuperation visuelle moyenne corrigee est de 0,35 ; 0,53 et 0,61 a 1, 2 et 6 mois. L’astigmatisme est chiffre successivement a 1,5D ; 1,13D et 0,96D. En revanche la densite endotheliale post-operatoire est significativement plus basse dans le groupe A (1 040 cellules/mm2 a 6 mois) que dans le groupe B (1 910 cellules/mm2 a 6 mois). Discussion Cette technique demande un certain temps d’apprentissage car la perte de cellules endotheliales secondaire aux manipulations du greffon diminue de moitie avec le temps et en respectant un certain nombre de principe chirurgicaux. Conclusion La greffe endotheliale est une technique extremement prometteuse chez les patients atteints de pathologie endotheliale car elle preserve la surface oculaire, elimine les complications dues a la trepanation et accelere la recuperation visuelle de maniere tout a fait spectaculaire.

Objectif Rapporter les resultats de deux nouvelles methodes de greffe endotheliale dans la prise en charge des pathologies endotheliales de la cornee. Materiels et Methodes Il s’agit d’une etude de cas, prospective, non comparative realisee sur 10 mois entre janvier et octobre 2006. Notre serie comprend 38 patients (26 femmes et 12 hommes), d’une moyenne d’âge de 69 ans et presentant une dystrophie endotheliale primitive de Fuchs dans 21 cas, une dystrophie du pseudophake dans 11 cas, une decompensation d’un greffon perforant dans 4 cas et une decompensation endotheliale a la suite d’un herpes dans 2 cas. La membrane de Descemet est separee du stroma a l’aide d’une spatule puis retiree a la pince (rhexis) par une incision de 3,2 mm. Dans 17 cas le greffon endothelial est preleve a la spatule sur une chambre anterieure artificielle. Dans 21 cas la separation sur le greffon donneur est realisee par injection d’air puis de viscoelastique. Dans tous les cas, le greffon endothelio-descemetique est enroule sur lui-meme dans une cartouche a injection puis extrait et deplie a l’aiguille dans la chambre anterieure. Suivant les cas, une bulle d’air ou de gaz est laissee en fin d’intervention. L’acuite visuelle, la refraction, la pachymetrie et la densite endotheliale ont ete evaluees a 2 mois puis 6 mois apres l’intervention. Resultats Au terme du suivi, le greffon endothelial est reapplique et la cornee Claire dans 37 cas sur 38. Un patient a du beneficier d’une greffe perforante en raison d’un decollement permanent du greffon. Dans le groupe des dystrophies de Fuchs, l’acuite visuelle corrigee est de 5/10 a 2 mois et 7/10 a 6 mois. Elle est de 0,21 a 2 mois et 0,35 a 6 mois dans les cas de dystrophies du pseudophake. L’astigmatisme moyen final est de 1,3 dioptries. La pachymetrie se stabilise a 1 mois (540 microns). La densite endotheliale est de 1 500 cellules/mm2 a 2 mois et 1 300 cellules/mm 2 a 6 mois. Discussion Malgre une plus grande difficulte technique, la rapidite de la recuperation visuelle est tout a fait spectaculaire en regard d’une greffe perforante, tout en eliminant les complications dues a la trepanation classique. Conclusion La greffe endotheliale est une technique extremement prometteuse chez les patients atteints de pathologie endotheliale. Les seules reserves concernent encore la vitalite a moyen et long terme de l’endothelium corneen greffe.

Objectif Analyser le retentissement des nouvelles techniques de greffes de cornee sur l’activite operatoire ainsi que sur la distribution des greffons corneens par les banques de cornees. Materiels et Methodes Il s’agit d’une etude retrospective de recensement realisee entre janvier 2003 et octobre 2006. Au cours de cette periode, nous avons comptabilise la part des differentes greffes lamellaires par rapport aux keratoplasties transfixiantes. Nous avons parallelement analyse l’evolution de l’activite de distribution des greffons en fonction de ces differentes indications. Resultats De 2003 a 2006, 350 greffes ont ete realisees. Au cours de ces 4 annees, la keratoplastie lamellaire profonde a represente successivement 48 %, 32 %, 27 % et 30 % des interventions; la keratoplastie transfixiante 51 %, 73 %, 72 % et 26 % des interventions. Enfin la greffe endotheliale qui ne represente que 1 % des indications en 2005, passe a 36 % en 2006. Sur la periode de 4 annees, 17 % des greffons conserves par la banque de cornees ne presentaient pas de qualite endotheliale suffisante pour une greffe perforante. 72 % d’entre eux ont pu etre utilises pour une greffe lamellaire. La preparation des greffons endotheliaux en 2006 a en revanche entraine une perte significative de greffons et impose le maintien d’une activite elevee de prelevement. Discussion Les pathologies stromales pures representent chaque annee un tiers des indications de greffes de cornees. Dans la majorite des cas, elles peuvent beneficier d’une greffe lamellaire profonde, intervention qui represente desormais une greffe sur quatre. Les pathologies touchant l’endothelium sont retrouvees dans 2 tiers des indications de greffes. Depuis l’apparition des techniques de greffe endotheliale, la place de la keratoplastie transfixiante pourrait etre reduite a un quart des indications. Ces differents changements ne manqueront pas de retentir sur l’activite des banques de cornees. Conclusion L’evolution actuelle des techniques de greffes de cornee laisse presager une diminution importante du taux de keratoplasties transfixiantes et necessitera sans aucun doute une adaptation des methodes de distribution des greffons par les banques de cornees.

Objectif Presenter les differentes etapes du prelevement de cornees de facon didactique afin de repondre aux exigences de qualite requises aujourd’hui et de faciliter la dissection des greffons destines aux nouvelles techniques de greffe. Materiels et Methodes Toutes les etapes du prelevement de la cornee ont ete photographiees puis disposees de maniere didactique sur notre affiche. Observation Nous insistons sur la desinfection du site operatoire, la necessite d’epargner l’endothelium corneen au moment du prelevement, les dimensions de la collerette sclerale, la restitution anatomique et le prelevement serologique. Discussion La qualite du prelevement de cornees est un des elements cles de la longue chaine menant du donneur au patient greffe. Dans l’espoir d’augmenter le nombre de greffons preleves dans certaines regions, l’Agence Francaise de Securite Sanitaire mene une reflexion afin que ce geste chirurgical aujourd’hui exclusivement realise par un medecin puisse etre confie a d’autres collaborateurs (techniciens de laboratoire, infirmieres…), ayant beneficie d’une formation specifique. Nous assistons par ailleurs au developpement de nouvelles techniques de greffes de cornees imposant un supplement de preparation des greffons. Ainsi les greffes endotheliales ou les greffons lamellaires anterieurs automatises necessitent une collerette sclerale importante pour un bon positionnement sur une chambre anterieure artificielle. Les greffes endotheliales necessitent un traumatisme endothelial minime au moment du prelevement. Conclusion La vocation de cette affiche est de trouver sa place dans les differents sites de prelevements de cornees afin de preciser et rappeler aux differents preleveurs nouvellement formes, les differents temps chirurgicaux de ce type de prelevement.