Faculty Bibliography

PURPOSE: To compare the efficacy of phototherapeutic keratectomy (PTK) to epithelial debridement and polishing of Bowman's membrane using a diamond burr (DB) in the treatment of recurrent corneal erosions associated with anterior basement membrane (ABM) dystrophy. DESIGN: Retrospective nonrandomized comparative trial. METHODS: Medical records of 39 patients (42 eyes) who underwent a PTK or DB procedure for recurrent corneal erosions associated with ABM dystrophy between March 1992 and June 2000 were reviewed. History of injury, prior treatment received, and the corneal slit-lamp findings were noted in all patients. In both procedures, all loose epithelium was completely removed. In PTK patients, 5 microm of Bowman's membrane was ablated with the excimer laser. In patients who underwent DB treatment, a hand-held battery-driven diamond dusted burr was used to gently and uniformly polish Bowman's membrane in the area of the epithelial defect. MAIN OUTCOME MEASURES: Symptomatic improvement, recurrence of painful erosions, development of haze, and change in the visual acuity. Statistical analysis was performed for comparison of data between the two groups. RESULTS: Fifteen eyes of 14 patients underwent PTK, and 27 eyes of 25 patients underwent epithelial debridement and DB treatment. In the PTK group, mild haze was seen in five (35.7%) eyes. Recurrence of painful erosions was seen in four eyes (26.7%). The mean follow-up was 17.6 +/- 5.7 months (range, 0.7-81.9 months). Best-corrected visual acuity was better in five eyes (35.7%) after the procedure and the same in nine eyes (64.3%). In the DB group, mild haze was seen in seven eyes (25.9%). Recurrence of painful erosions was seen in three eyes (11.1%). The mean duration of follow-up was 6.7 months (range, 1-24.2 months). Best-corrected visual acuity was better in 3 eyes (14.3%), the same in 17 eyes (81%), and worse in 1 eye (4.8%) after the procedure. Final visual acuity was not available for one eye in the PTK group and 6 eyes in the DB group. There was no statistically significant difference in haze (Fisher's exact test, P = 0.38), recurrence of erosions (Kaplan-Meier analysis with log rank, P = 0.73), and vision being better or the same (Fisher's exact test, P = 0.6) between the PTK and DB groups. CONCLUSIONS: Both PTK and DB treatment are effective methods of treating recurrent corneal erosions associated with ABM dystrophy. Diamond burr treatment, being a simpler, less expensive office procedure with a tendency toward lesser incidence of haze and recurrence in this study, seems to have advantages over PTK in the treatment of recurrent corneal erosions. Further prospective studies are required to confirm the long-term efficacy of DB treatment in the management of recurrent corneal erosions associated with ABM dystrophy

PURPOSE: To describe a case in which the recognition by the ophthalmologist of Kayser-Fleischer rings played a crucial role in the diagnosis of Wilson disease (hepatolenticular degeneration).DESIGN: Interventional case report.METHODS: An 18-year-old woman was found to have bilateral peripheral golden brown pigment deposits at the level of the Descemet membrane consistent with Kayser-Fleischer rings. She initially denied systemic symptoms.RESULTS: The serum cerumoplasmin level of the patient was normal. Liver function tests were also normal. Further evaluations with 24-hour urine copper assay and liver biopsy were positive for Wilson disease. She underwent anticopper therapy and, 6 months later, reported improved concentration and balance. No appreciable change occurred in the Kayser-Fleischer rings.CONCLUSION: Wilson disease occurs when a defective copper-transporting enzyme in the liver results in toxic copper accumulation in multiple organs. Because of the insidious nature of the disease, patients may not seek medical attention until severe irreversible damage has occurred. By diagnosis of Kayser-Fleischer rings, ophthalmologists may play a critical role in the early recognition and proper evaluation of such patients

PURPOSE: To report a case of sclerokeratitis caused by Nocardia asteroides in a soft contact lens wearer. CASE REPORT: A 65-year-old male presented with a 2-month history of a corneal ulcer in the left eye. He wore two weekly disposable soft contact lenses on an extended basis. He revealed his history of gardening before the onset of symptoms. On examination, his best-corrected visual acuity was 20/30 in the right eye and 20/400 in the left eye. In the left eye, there was conjunctival injection. His cornea showed multiple patchy infiltrates, with a feathery border that was raised and involved up to the midstroma. There was a 3+ anterior chamber reaction. Corneal scrapings were performed for smears and cultures. Topical 2% amikacin sulfate every half hour along with oral clarithromycin therapy was initiated. On follow-up, the sclera lesions worsened. RESULTS: Smears of corneal scrapings revealed gram-positive filamentous bacteria in Gram's stain. The cultures grew Nocardia asteroides. The patient was switched to trimethoprim-sulfamethoxazole (Bactrim DS, Roche Laboratories, Nutley, NJ) as the sclera was involved. The patient responded to treatment, and the infection resolved. When last seen, approximately 4 months after his initial presentation to us, his visual acuity was 20/40 in the affected eye. There was corneal scarring, and the adjacent sclera showed thinning. CONCLUSIONS: Nocardia sclerokeratitis can be associated with contact lens wear. Nocardia should be considered in the differential diagnosis of a corneal ulcer with an indolent progressive course with feathery infiltrates. Topical amikacin and systemic trimethoprim-sulfamethoxazole are effective drugs in the treatment of nocardial corneal infection with scleral involvement

PURPOSE: This study was designed to identify factors that may help to determine the likelihood of a patient with keratoconus undergoing a penetrating keratoplasty (PK) after referral to a cornea service. METHODS: A retrospective chart review of 109 patients from a corneal referral practice was undertaken to identify clinical characteristics at presentation that were predictive of subsequent PK. RESULTS: Overall, during an average follow-up of 10.9 years, 39 (35.8%) did not have a PK for keratoconus in either eye, 34 (31.2%) had a PK in one eye, and 36 (33.0%) had a PK in both eyes. The presence of corneal scarring and steep keratometry values were significant risk factors for subsequent PK. CONCLUSION: In a corneal referral practice, 64.2% of patients go on to PK in one or both eyes during long-term follow-up. The presence of scarring and high keratometry values at initial presentation may help to predict the likelihood of requiring a PK and may aid in patient counseling

PURPOSE: To identify current indications and trends in indications for penetrating keratoplasty and associated procedures. METHODS: Retrospective chart review of all patients who underwent penetrating keratoplasty at Wills Eye Hospital from January 1, 1996 to December 31, 2000. RESULTS: A total of 1,529 corneal transplants were performed during this 5-year period. The leading indications for penetrating keratoplasty were pseudophakic bullous keratopathy (PBK) in 416 (27.2%) cases, followed by regraft in 276 (18.1%), keratoconus in 236 (15.4%), and Fuchs endothelial dystrophy in 233 (15.2%) cases. Of the 416 PBK cases, 271 (65.1%) were associated with posterior chamber intraocular lenses (PC IOLs), 141 (33.9%) with anterior chamber intraocular lenses (AC IOLs), and four (1%) with iris-fixated lenses. Of these 141 AC IOLs, 107 (75.9%) were closed-loop and 34 (24.1%) were open-loop. Of the 416 PBK cases, in 281 (67.5%) cases, the IOL was not exchanged; in 127 (30.5%) cases, the IOL was exchanged; in six (1.5%) cases, the IOL was repositioned; and in two (0.5%) cases, the IOL was removed at the time of surgery. Of the 271 PC IOLs, 248 (91.5%) were not exchanged and 19 (7.1%) were exchanged. Of the 141 AC IOLs, 33 (23.4%) were not exchanged and 104 (73.7%) were exchanged (p = 0.001). CONCLUSIONS: Pseudophakic bullous keratopathy remains the leading indication for corneal transplantation at our institution followed by regraft. The percentage of PBK cases associated with PC IOLs has increased significantly, whereas the percentage associated with AC IOLs has decreased. The frequency of regraft has also increased significantly