Faculty Bibliography

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

PURPOSE: To report a rare complication in which the patient accidentally removed the laser in situ keratomileusis corneal flap. METHODS: Interventional case report. A 35-year-old woman underwent uncomplicated laser in situ keratomileusis surgery. Ten days after surgery, she inserted a soft contact lens into the right eye to improve her vision. She tried to remove the contact lens, but had pain and bleeding. She was referred 10 days later with a diagnosis of loss of flap. RESULTS: On examination, she had a best-corrected visual acuity of 20/70 in the right eye. The right eye examination revealed no corneal flap, mild corneal edema, and significant haze. A central epithelial defect was found. CONCLUSION: Accidental corneal flap removal can rarely follow laser in situ keratomileusis surgery. This complication provides insight into the weak adhesion of the flap onto the stromal bed after laser in situ keratomileusis surgery and, hence, the inherent risk of traumatic flap dislocation or amputation, which needs to be explained to the patient

PURPOSE: To describe a post-LASIK patient with decreased vision and a chalazion of the upper eyelid. METHODS: A 46-year-old man was referred with decreased vision of 1 month's duration. He underwent bilateral uncomplicated LASIK for myopic astigmatism 1.5 years and bilateral enhancements 1 year previously. He had 20/20 uncorrected vision in both eyes after those procedures. He developed a chalazion of his right central upper eyelid 1 month prior with simultaneous blurring of vision. On our examination, his uncorrected visual acuity was 20/60 in the right eye. Complete eye examination including refraction, computerized corneal topography, and pachymetry were done. RESULTS: With a manifest refraction of +1.25 +0.50x80, the visual acuity in the right eye improved to 20/20. Computerized corneal topography revealed circular central corneal flattening in both eyes, much greater in the right eye than the left eye. The location of the chalazion with the right eye closed corresponded to the area of central corneal flattening. The central power from the corneal topography was 39.4 D OD and 40.8 D OS. He was diagnosed as having acquired hyperopia associated with chalazion-induced central corneal flattening of the right eye. Chalazion-induced hyperopic change on topography disappeared, and his uncorrected vision improved to 20/20 in the left eye as the chalazion resolved completely. CONCLUSION: In post-LASIK patients with decreased vision and topography changes late after surgery, periocular masses should be considered in the differential diagnosis. Decreased corneal thickness and rigidity after LASIK might be a predisposing factor to external compression-induced curvature changes

PURPOSE: To evaluate indications, success rate, and complications of tarsorrhaphy in a cohort of cornea and external disease patients. METHODS: In this study, charts of patients who underwent tarsorrhaphies from January 1, 1995, to September 30, 2000, were retrospectively evaluated. Information reviewed included patient age and sex, indication for tarsorrhaphy, duration of signs and symptoms before tarsorrhaphy, time to epithelial healing after tarsorrhaphy, type of tarsorrhaphy (temporary/permanent), complications, timing of tarsorrhaphy removal, recurrence of signs and symptoms after complete or partial opening of the tarsorrhaphy, number of tarsorrhaphies needed to be replaced or extended, and duration of follow up. RESULTS: Seventy-seven patients were included in this study. Indications for a tarsorrhaphy were persistent epithelial defects or other ocular surface problems associated with neurotrophic ulcers, penetrating keratoplasty (PK), postinfection, exposure keratopathy, surgery other than PK, dry eye syndrome, radiation keratopathy, ocular cicatricial pemphigoid, Stevens-Johnson syndrome, entropion, and application of tissue adhesive. The epithelial defects in 70 (90.9%) of the 77 eyes completely resolved. Overall, the mean duration of signs and symptoms before tarsorrhaphy was 89.8 +/- 27.8 days, and time-to-healing after tarsorrhaphy was 18.0 +/- 2.0 days. The difference between the duration of the signs and symptoms before tarsorrhaphy and time-to-healing after tarsorrhaphy was statistically significant ( p = 0.01). Of the 77 tarsorrhaphies, 24 (31.2%) were temporary and 53 (68.8%) were permanent. Complications after tarsorrhaphy included trichiasis, adhesion between upper and lower lids after tarsorrhaphy lysis, premature opening of the temporary tarsorrhaphy, pyogenic granuloma, and keloid formation of the eyelid. CONCLUSION: Tarsorrhaphy is a very effective and safe procedure in the management of nonhealing epithelial defects and other surface problems, with a 90.9% success rate and only minor complications

PURPOSE: To report three cases of seemingly unilateral dystrophy indistinguishable from type I classic lattice corneal dystrophy. METHODS: Case study of three patients. Three patients, a 31-year-old man, a 44-year-old woman, and a 41-year-old man had multiple lattice lesions in one eye and an apparently healthy fellow eye. Two of these patients underwent penetrating keratoplasty because of poor vision. RESULTS: Histopathologic examination of the excised corneal button of patient 2 showed amyloid deposits consistent with lattice. In the third patient, lattice lesions were noted in the other eye nearly 13 years after he was first examined. CONCLUSIONS: Lattice corneal dystrophy is rarely unilateral. Lattice, even in unilateral cases, may cause significant vision loss to warrant penetrating keratoplasty. Lattice lesions may develop in the fellow eye many years later. This possibility should be explained to all patients with apparently unilateral lattice corneal dystrophy

PURPOSE: We evaluated the performance of the SoftPerm contact lens (Wesley Jessen) in patients with irregular astigmatism, usually due to keratoconus or after penetrating keratoplasty (PK), who were unable to befitwith, or intolerant of, rigid gas permeable (RGP) contact lenses. METHODS: A retrospective study of patients fit with SoftPerm lenses in the Cornea Department at Wills Eye Hospital between March 1985 and March 2000 was performed. RESULTS: Thirty-five cases were reviewed, with follow-up available in 33 cases. Most of the eyes had irregular astigmatism secondary to keratoconus (22/35,62.9%) or PK (10/35,28.6%) and had failed a trial of RGP lenses. The mean logMAR visual acuity with SoftPerm lenses was 0.13+/-0.18 (range -0.12 to 0.6). In 25 cases in which comparison with glasses or RGP lenses was possible, SoftPerm lenses provided better visual acuity than glasses in 17/25 cases (68%) with a mean difference of -0.24 (P = 0.001, paired t-test); visual acuity with SoftPerm lenses was better than RGP visual acuity in 13/25 cases (52%), with a mean difference of -0.06 (P = 0.07, paired t-test). Complications included broken lenses (16/33,48.5%), giant papillary conjunctivitis (GPC) (9/33, 27.3%), and peripheral corneal neovascularization (9/33, 27.3%). The GPC and peripheral corneal neovascularization were often delayed in presentation. The major subjective complaint was discomfort (13/33, 39.4%). At the last follow-up, the SoftPerm lens was still in use in 22/33 cases (66.7%). Discomfort was the most common reason for discontinuation. The mean duration of lens wear was 52.5+/-31.7 months, range 3 to 110 months. CONCLUSIONS: The SoftPerm lens can provide satisfactory visual correction in many cases of irregular astigmatism with RGP failure. However, problems such as frequent breakage, GPC, peripheral corneal neovascularization, and discomfort necessitate close follow-up

PURPOSE: Pennsylvania Act 102 implemented in March 1995 required all acute care hospitals in Pennsylvania to routinely refer all deaths to the Organ Procurement Organization for determination of suitability for organ/tissue donation. This study analyzed the effect of the law on eye donation. METHODS: Retrospective analysis of the total number of referrals and the actual number of eye donations from 62 hospitals in Pennsylvania to the Lions Eye Bank of Delaware Valley was performed for the years 1993 to 1998. Information gathered included donor's age, gender, race, cause of death, referring institution, and result of referral. RESULTS: From 1993 to 1998, the total numbers of referrals were 988, 1,647, 8,101, 21,123, 21,783, and 22,987, and the numbers of donors were 570, 574, 660, 644, 594, and 568, respectively. The increase in the number of donors after implementation of the law was not commensurate with the number of referrals. This was caused by a disproportionate increase in the number of referrals older than 70 years of age (from a mean of 33% to 52%), which exceeded the donor age limit of 69 years, and also to a lower family consent rate (from a mean of 48% to 24%). CONCLUSIONS: Well-designed state legislation with proper implementation greatly increased hospital referrals for eye donation. However, there was only a small increase in the number of eye donors because many of the referrals were beyond the acceptable upper age limit for eye donation. A small increase in the donor age limit would increase the number of eye donations without having to expand the potential donor pool. Education of the public may help to improve the family consent rate

PURPOSE: To determine the benefit of bilateral penetrating keratoplasty with regard to binocular vision. METHODS: We compared patients who underwent corneal transplantation bilaterally with patients who had successful corneal transplantation in one eye and corneal disease in the other eye. Specifically, changes in fusion, stereopsis, and binocular vision function were analyzed. A questionnaire regarding performance of daily tasks was given. RESULTS: Patients with bilateral keratoplasty performed better in all the analyzed functions. Fusion was achieved by 81.25% in the unilateral group versus 100% in the bilateral group (p = 0.15). Stereopsis was present more in the bilateral group (100% vs. 62.5%, p = 0.008) and the quantity of stereopsis was significantly better in the bilateral group (121 seconds of arc vs. 1,284 seconds of arc, p = 0.014). 88.8% of the patients subjectively improved in daily activities after second eye surgery. CONCLUSION: There are objective and subjective improvements after bilateral penetrating keratoplasty