Faculty Bibliography

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: 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 of full-thickness corneal laceration and intraocular foreign body in an eye that underwent laser-assisted in situ keratomileusis (LASIK). METHODS: A 43-year-old man underwent uneventful bilateral LASIK. Seventeen months after LASIK, the patient suffered penetrating trauma to the right eye while hammering metal without safety glasses. Examination on the night of the injury showed an uncorrected visual acuity of 20/30 in the right eye. Slit-lamp biomicroscopy showed a 2.4-mm full-thickness peripheral corneal laceration at the 11-o'clock position extending over the edge of the previous LASIK flap and a foreign body partially embedded in the superior iris. He was started on prophylactic topical and intravenous antibiotics. Under general anesthesia, the corneal laceration was repaired, and the intraocular foreign body was removed without any complications. RESULTS: At the follow-up visit 9 months after the surgery, the uncorrected visual acuity was 20/25 in the right eye. On slit-lamp examination, the corneal sutures and the well-positioned LASIK flap were in place. CONCLUSION: Penetrating trauma of the cornea did not lead to flap-related complications in this post-LASIK eye. Repair of the corneal laceration and removal of the intraocular foreign body after LASIK were managed without complications. Care must be taken to try not to manipulate or lift the LASIK flap during corneal laceration repair

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

PURPOSE: To evaluate the clinical efficacy and safety of silicone punctal plugs in various ocular surface disorders. PATIENTS AND METHODS: Medical records of patients who underwent silicone punctal plug insertion from January 1996 to November 2000 were retrospectively reviewed. The clinical data collected included sex and age of the patients, indications for plug insertion, symptoms, corneal fluorescein staining and frequency of lubricant use at baseline and at 4 +/- 2 weeks after the insertion, location (upper versus lower punctum), initial versus replacement plug, spontaneous extrusion or removal of the plug, and percentage of complications and punctum cauterization. RESULTS: There were 203 eyes of 153 patients (126 women and 27 men) in the study group. The total number of silicone punctal plug procedures was 312. Dry eye syndrome was the most common indication for punctal plug treatment (127 eyes, 62.5%), followed by epitheliopathy after penetrating keratoplasty (32 eyes, 15.8%). The symptoms improved in 150 (73.9%) of 203 eyes at 4 +/- 2 weeks' follow-up. The mean score of the fluorescein staining of the cornea was reduced from 2.7 +/- 0.1 to 1.3 +/- 0.1 with silicone punctal plug treatment at 4 +/- 2 weeks' follow-up. This reduction was statistically significant (p< 0.01). The overall success rate at 4 +/- 2 weeks follow up was 76.8%. The frequency of the lubricant use was significantly decreased with punctal plug treatment (p< 0.001). Considering all plugs, the estimated probability of plug retention was 49.4% with 85.1 +/- 7.3 weeks as the mean survival time. There was no statistical difference in plug retention rates between lower (49.6%) and upper (48.7%) plugs (p= 0.15). Retention rate of first plugs (53.5%) was significantly higher than that of second plugs (32.0%) (p= 0.05). The spontaneous total extrusion of silicone punctal plug was the most common complication in our study (158 plugs, 50.7%). The plug was removed in 14 eyes (14 plugs, 6.9%) because of epiphora in 11 eyes and conjunctival erosion in three eyes. The percentage of punctum cauterization performed in our population was 10.8%. CONCLUSIONS: Punctal plug insertion is a simple, effective, safe, and reversible method to treat aqueous tear deficiency and other ocular surface diseases, such as epitheliopathy after penetrating keratoplasty, superior limbic keratoconjunctivitis, neurotrophic keratitis, recurrent corneal erosions, and toxic epitheliopathy not controlled by lubrication with preservative-free tears. However, spontaneous extrusion of silicone plug occurs commonly. Careful choosing of the optimal plug size and close follow-up are recommended to ensure the success of the treatment

OBJECTIVE: To evaluate clear corneal wound infections after phacoemulsification. MATERIALS AND METHODS: The medical records of 7 patients with clear corneal wound infections after phacoemulsification were reviewed retrospectively. Data that were reviewed included patient age, sex, onset of symptoms and signs after surgery, possible risk factors for infection, concomitant ocular disease, use of perioperative prophylactic antibiotics and steroids, culture and antibiotic sensitivity results, treatment regimen, and outcome. RESULTS: The median onset of signs and symptoms after surgery was 10 days (range, 4-60 days). Corneal cultures yielded methicillin-resistant Staphylococcus aureus in 2 cases, Streptococcus pneumoniae in 1 case, and Staphylococcus epidermidis in 1 case. Cultures yielded no microorganisms for 1 patient. Corneal cultures were not obtained in 2 patients. In 3 of the 4 culture-positive cases, the isolated microorganisms were resistant to the perioperative prophylactic antibiotics (fluoroquinolones and tobramycin) that were used. No possible risk factors were noted except use of topical steroids 4 times a day without antibiotic coverage for iritis before referral in one of our patients. Six of these 7 wound infections healed with topical antibiotic therapy. One of the patients required lamellar keratectomy and conjunctival flap for complete healing. In 4 of the 7 cases, best-corrected visual acuity at the last follow-up visit was better than 20/40. CONCLUSIONS: Clear corneal wound infection after phacoemulsification is a serious complication of cataract surgery. Infections are caused by gram-positive organisms sensitive to bacitracin and the combination of trimethoprim-sulfamethoxazole but often resistant to aminoglycosides and/or fluoroquinolones