Faculty Bibliography

PURPOSE: To describe a case of fungal keratitis in a soft contact lens wearer. METHODS AND RESULTS: A 57 year old female, compliant, frequent replacement soft contact lens wearer, with a possible prior history of herpes simplex keratitis, presented with pain and injection of her left eye of four weeks duration. Gram stain of a corneal ulcer of the left eye revealed fungal organisms and cultures grew Fusarium solani. The infiltrate responded to topical and systemic antifungal agents, but a corneal perforation developed which required a therapeutic penetrating keratoplasty. CONCLUSIONS: Fungal infections are a cause of corneal ulcers in contact lens wearers. Despite the use of topical and systemic antifungal agents, fungal ulcers frequently require surgical intervention

PURPOSE: To describe the treatment of Schnyder's crystalline dystrophy (SCD) with excimer laser phototherapeutic keratectomy (PTK). METHODS: Chart review of three patients (four eyes) with SCD treated with PTK between March 1992 and December 1998. Pre- and posttreatment visual acuity, subjective glare, photophobia, manifest refraction, ultrasound pachymetry, hyperopic shift, and biomicroscopic findings were studied. Brightness acuity testing (BAT) was evaluated in two eyes. RESULTS: Four eyes were treated during the study period. The average best corrected visual acuity (BCVA) improved from 20/175 to 20/40 under bright conditions. All patients reported subjective improvement in glare and photophobia. No visually significant recurrence was observed during the follow-up period which ranged from seven months to three years. The mean spherical equivalent refractive shift was +3.28 diopter (D). One patient developed irregular astigmatism from an eccentric ablation. No vision threatening complications were observed. CONCLUSION: PTK can be effective at improving visual symptoms in patients with SCD. It can be a useful therapeutic alternative to lamellar or penetrating keratoplasty in these patients

PURPOSE: To study the predisposing conditions, treatments, and visual outcomes of nontraumatic corneal perforations. METHODS: A retrospective chart review was conducted of all nontraumatic corneal perforations seen between January 1992 and December 1998, with > or = 3 months of follow-up, at the Cornea Service Wills Eye Hospital. RESULTS: A total of 40 nontraumatic corneal perforations was analyzed. Sixty-two percent of the cases were female. At presentation, 35 of 40 eyes (87.5%) had best corrected visual acuity of 20/200 or worse. The most common diseases associated with perforations were keratoconjunctivitis sicca (12 eyes, 30%), bacterial keratitis (6 eyes, 15%), exposure keratopathy (5 eyes, 12.5%), and herpes simplex virus (HSV) keratitis (4 eyes, 10%). Visual acuity improved > or = 2 Snellen lines in 3 of 8 eyes (37.5%) treated with penetrating keratoplasty, 5 of 14 eyes (35.7%) treated with tissue adhesive, and 1 of 12 eyes (8.3%) given medical treatment. After allowing for the different levels of presenting vision, treatment modality was not significantly related to final visual outcome. CONCLUSION: Keratoconjunctivitis sicca is the most common underlying disease associated with nontraumatic corneal perforation. Corneal perforations were managed successfully using tissue adhesive, medical therapy, or penetrating keratoplasty. Treatment depended on the characteristics of the perforation and on the visual potential of the eye

PURPOSE: To report the spectrum of fungal keratitis at Wills Eye Hospital, Philadelphia. METHODS: We reviewed the records of 24 cases of culture-positive fungal keratitis treated from January 1991 to March 1999 at Wills Eye Hospital. Risk factors, fungal identification, antifungal treatment, and outcomes were evaluated. RESULTS: The study included 24 eyes (24 patients). Fourteen patients (58.3%) were female. The mean age was 59 years (range, 19-86 years). Predisposing factors included chronic ocular surface disease (41.7%), contact lens wear (29.2%), atopic disease (16.7%), topical steroid use (16.7%), and ocular trauma (8.3%). Early identification of fungal elements was achieved by staining of corneal scrapings in 18 cases (75%). Half of the cases (12 eyes) had corneal infections caused by yeast, and the other half by filamentous fungi. Candida albicans was the most commonly isolated organism (45.8%), followed by Fusarium sp (25%). Natamycin and amphotericin B were the topical antifungals most frequently used, while systemic treatment commonly used included fluconazole, ketoconazole, or itraconazole. Six patients (25%) had penetrating keratoplasty during the acute stage of infection. After a mean follow-up of nine months, 13 eyes (54.1%) had the best corrected visual acuity 20/100 or better. CONCLUSIONS: In contrast to other studies from the northern United States, we found Fusarium sp the most commonly isolated filamentous fungus. In our series, C. albicans was the most frequent cause of fungal keratitis, and a past history of ocular trauma was uncommon

PURPOSE: To report the surgical outcomes of treatment for ocular surface squamous neoplasms. METHODS: Retrospective review of squamous neoplasms of the ocular surface managed at a cornea center over a 15-year period. Surgical treatment was divided into two methods. The procedure was identical within each group. One group of patients was treated with simple excision of the lesion. The second group of patients was treated with excision followed by focal cryotherapy to the involved limbus and/or conjunctival margin. Follow-up is reported. RESULTS: A total of 28 lesions were reviewed. Included were 20 primary tumors and 8 recurrent tumors referred following initial treatment at other centers. Histopathologic diagnoses included 1 actinic keratosis, 7 dysplasias, 18 carcinomas in situ, and 2 invasive squamous cell carcinomas. The rate of recurrence for primary tumors was 28.5% with simple excision and 7.7% for excision combined with cryotherapy (p = 0.27). The rate of recurrence for recurrent tumors was higher: 16.6% for tumors treated with excision and cryotherapy and 50% (one in two) for lesions treated with simple excision (p = 0.46). CONCLUSION: Simple excision of ocular surface squamous neoplasms appears to result in a higher recurrence rate when compared to excision with adjunctive cryotherapy. Judicious cryotherapy to the involved limbus and conjunctival margins results in recurrence rates comparable with other, more extensive cryotherapy procedures. This technique of cryotherapy has very few adverse effects on the eye

OBJECTIVE: To evaluate the indications for and outcomes of repeat penetrating keratoplasty over a 7-year period and compare them to a similar study over the prior 6-year period at the same institution. DESIGN: Retrospective noncomparative case series. PARTICIPANTS: Two hundred twenty-three consecutive repeat corneal transplants performed by one of five corneal surgeons between 1989 and 1995 were studied. MAIN OUTCOME MEASURES: Reasons for primary and regraft failure, indications for the initial corneal graft, graft clarity, and best-corrected visual acuity were measured on each patient. RESULTS: Between 1989 and 1995, 16% (271 of 1689) of transplants performed by our cornea group were regrafts compared with 9% (165 of 1860) in the period from 1983 to 1988 (P < 0.01). The most common indications for penetrating keratoplasty before regraft were pseudophakic bullous keratopathy (27%, 61 of 223), failed graft (20%, 44 of 223), Fuchs' dystrophy (11%, 24 of 223), aphakic bullous keratopathy (9%, 21 of 223), keratoconus (8%, 17 of 223), and herpes simplex keratitis (6%, 14 of 223). Compared with the prior study period of 1983 to 1988, an increase was revealed in the incidence of failed graft (11% to 20%, P = 0.03), and a decrease was revealed in the incidence of aphakic bullous keratopathy (19% to 9%, P = 0.01). Of the 223 regrafts, 55 (25%) failed during the study period (range, 1 month to 7.5 years; mean 2.1 years). Eleven percent (6 of 55) of regraft failures occurred within 6 months, and 55% (30 of 55) failed within 18 months. Of the 150 regrafts with 2 years follow-up (mean, 3.9 years), 111 (74%) had clear grafts. A best-corrected visual acuity of 20/20 to 20/40 was achieved in 41% (46 of 111), 20/50 to 20/100 in 32% (36 of 111), 20/200 to 20/400 in 21% (23 of 111), and counting fingers to no light perception in 5% (6 of 111). CONCLUSIONS: Failed grafts are increasing as an indication for penetrating keratoplasty. Graft clarity and visual acuity results continue to be very good, supporting the use of repeat corneal transplantation