Faculty Bibliography

PURPOSE: To identify changing trends in indications for penetrating keratoplasty and associated surgical procedures. METHODS: Review of charts from all patients who underwent penetrating keratoplasty at Wills Eye Hospital from January 1, 1989 through December 31, 1995. RESULTS: A total of 2,442 corneal transplants were performed in 2,186 patients. The leading indication for penetrating keratoplasty was pseudophakic corneal edema, accounting for 634 cases (26.0%); 54.7% of them were associated with anterior chamber intraocular lenses, 36.4% with posterior chamber intraocular lenses, and 3.1% with iris-fixated intraocular lenses. Regraft (17.8%), Fuchs' dystrophy (15.7%), and keratoconus (13.2%) followed pseudophakic corneal edema in frequency. Cataract extraction, with or without intraocular lens implantation, was combined with penetrating keratoplasty in 439 cases of 1,264 phakic eyes (34.7%). Intraocular lens exchange was performed in 285 of the 634 cases of pseudophakic corneal edema (44.9%). CONCLUSION: Pseudophakic corneal edema was the leading indication for penetrating keratoplasty, with an increasing number of cases associated with posterior chamber intraocular lenses during the study period (p = 0.001). The number of regrafts steadily increased between 1989 and 1995 (p = 0.001), being the second most common indication for corneal transplantation since 1992

This article presents three cases of decreased vision due to acquired hyperopia, which were caused by a chalazion of the upper eyelid. Through manifest refraction and computerized corneal topographic analysis, acquired hyperopia associated with central corneal flattening was revealed. These findings were responsible for the blurred vision that was reversed by chalazion resolution or removal. Although not usually considered a risk factor for refractive disorders other than astigmatism, chalazia of the upper eyelid can present as a decrease in vision associated with reversible central corneal flattening and acquired hyperopia

PURPOSE: The purpose of this study was to evaluate the outcome of patients with healed moderate to severe contact lens-associated corneal infectious ulcers who were re-fit with contact lenses. METHODS: We retrospectively studied patients who were fit with contact lenses on our service and who had had moderate to severe corneal infectious ulcers associated with previous contact lens use. Six patients were included in the study. RESULTS: Gas permeable contact lenses were fit in five patients, and a soft contact lens was fit in one patient. Successful fit was achieved in all cases and visual acuities were equal to or better than 20/30 in all patients. No significant complications were observed after a mean follow-up of 23 months (range, 6-45 months). CONCLUSION: In this small series of patients with a history of moderate to severe contact-lens related infectious keratitis, no complications were observed after contact lenses were refit. Contact lens wear in patients with a history of infectious keratitis may be safe and useful in order to achieve visual rehabilitation

PURPOSE: To evaluate the long-term graft survival and complications of flexible, open-loop anterior-chamber intraocular lenses in patients with penetrating keratoplasty for pseudophakic or aphakic bullous keratopathy. METHODS: We reviewed charts of all consecutive patients who underwent penetrating keratoplasty for pseudophakic or aphakic bullous keratopathy combined with implantation of a flexible, open-loop, anterior-chamber intraocular lens at our institution between 1983 and 1988. One-hundred one eyes of 99 patients were evaluated. Graft-survival rates were calculated by using the Kaplan-Meier actuarial method. RESULTS: Mean follow-up was 49.8 months (range, 1-144). The probability of graft survival at 1, 2, 4, 6, and 8 years was 93, 87, 78, 65, and 65%, respectively. A total of 25 (24.8%) grafts failed. Progressive corneal edema without signs of rejection was the most common finding in patients with failed grafts (10 eyes, 40%). The most frequent complication observed was newly diagnosed or worsening of preexisting glaucoma (46 eyes, 45.5%). CONCLUSIONS: Our long-term results support flexible, open-loop anterior-chamber intraocular lenses as a reasonable option, at the time of penetrating keratoplasty, in patients with pseudophakic and aphakic bullous keratopathy

PURPOSE: The authors review a large series of patients with bullous keratopathy (BK) to analyze the frequency of ulcerative keratitis, and determine the contributory roles of bullae, bandage soft contact lenses, steroids, and prophylactic antibiotics. METHODS: A retrospective review of all cases of pseudophakic or aphakic bullous keratopathy presenting to the cornea service between January 1, 1986 and September 1, 1995 was performed. The influence of time, bullae, bandage contact lenses, steroids, and prophylactic antibiotics was evaluated by actuarial methods and multivariate analysis. RESULTS: Nine hundred eighteen patients were included in this study, 44 (4.7%) of whom had infectious or inflammatory complications; 813 cases were available for statistical analysis. Steroids (P < 0.0001), bandage soft contact lens use (P = 0.004), and bullae (P = 0.01) had statistically significant independent effect on the risk of developing ulcerative keratitis, and the combination of steroids and bandage lenses yielded the highest risk (P < 0.001). Propylactic antibiotic use paradoxically had a statistically significant association with ulcerative keratitis in these patients (P = 0.01). Increasing BK time was also associated with ulcer development, and the risk remained relatively constant over the 60 months of the study. Streptococcus was the most frequent organism cultured. CONCLUSIONS: Ulcerative keratitis developed in 4.7% of patients with bullous keratopathy. Prolonged BK time alone was a risk factor for infection. The strongest single additional risk factor for ulcer development was steroid use, followed by bandage soft contact lens use, and their simultaneous use had the greatest effect. The presence of bullae was also a risk factor for infection, and prophylactic antibiotic use did not prevent ulcer development

OBJECTIVE: To prospectively evaluate the clinical importance of antibiotic sensitivities for the management of corneal ulcers. METHODS: Thirty-two consecutive patients referred to the Cornea Service at Wills Eye Hospital, Philadelphia, Pa. between October 1, 1993, and May 31, 1994, with a culture-positive corneal ulcer were studied prospectively. Broad-spectrum empirical antibiotic therapy with intensive topical fortified antibiotics was initiated after smear and culture results were obtained. The therapy was modified based on clinical appearance, stain results, or organism identification. Clinicians were masked to the sensitivity results. RESULTS: Fifteen patients healed after receiving the initial empirical antibiotic therapy (group 1). The antibiotic regimens of 6 patients were modified after the stain and/or culture results were available, although the clinical appearance suggested continued improvement while taking the initial regimen (group 2). Eleven patients had ulcers that either failed to improve or worsened after receiving the initial empirical therapy (group 3). Seven of these patients ultimately improved with a change in therapy; treatment failed in 4 patients. Nine patients (5 for whom antibiotic therapy succeeded and 4 for whom it failed) should have been adequately treated by the initial antibiotic therapy, according to sensitivity results. In the remaining 2 patients, in vitro sensitivity testing did not include the antibiotics used for the initial treatment. In all cases, the organisms were sensitive to the empirically altered regimen of antibiotics. CONCLUSIONS: These preliminary results suggest that routine antibiotic susceptibility tests do not provide clinically useful information for the management of corneal ulcers. The identification of the organisms based on the results of smears and cultures was sufficient for the selection and modification of topical antibiotic therapy

PURPOSE: The purpose of this study was to describe the outcome of patients with filtering blebs who were fit with contact lenses. METHODS: We retrospectively studied patients with filtering blebs secondary to glaucoma or cataract surgery who were fit with contact lenses. Eight eyes from seven patients were identified. RESULTS: Five patients (six eyes) were fit with gas permeable contact lenses and two patients (two eyes) were fit with soft contact lenses. Successful fits were achieved in all patients. No complications were observed after a mean follow-up of 64.6 +/- 28.5 months. CONCLUSIONS: No significant complications were recorded in our series of patients with filtering blebs who were fit with contact lenses. We think that when indications for fitting contact lenses are justified, patients with filtering blebs are acceptable candidates for contact lens use. However, adequate selection of cases, careful contact lens fitting, patient education, and close follow-up are necessary

BACKGROUND AND OBJECTIVE: The authors sought to determine whether the immediate corneal topographic changes induced by selective suture removal for astigmatism after keratoplasty were stable over time. PATIENTS AND METHODS: Computerized videokeratoscopic images were obtained prior to and immediately following suture removal in 14 patients, and then again at the next postoperative visit 4 to 6 weeks later. These images were analyzed and statistically compared for central corneal power and vector of the central 3-mm corneal astigmatism. RESULTS: Most of the topographic changes induced by suture removal occurred immediately. However, continued shifting in corneal curvature did take place over the subsequent 4 to 6 weeks. Unpredictable shifts were more pronounced in patients whose surgery had been performed more than 20 months prior to suture removal. CONCLUSION: Computerized videokeratoscopy graphically elucidates continued shifts in corneal topography following the removal of sutures for the control of astigmatism after keratoplasty

BACKGROUND AND OBJECTIVE: The efficacy of the surgical management of pterygium with conjunctival autograft was evaluated. PATIENTS AND METHODS: In a retrospective survey, the records of 94 consecutive patients who underwent surgery for pterygium between 1984 and 1993 were reviewed. Only the first pterygium procedure for each patient performed at Wills Eye Hospital was included. The statistical technique of survival curve analysis by the Kaplan-Meier product limit was used to analyze the results separately after the removal of primary and recurrent pterygia. RESULTS: Thirty-one patients with primary pterygium underwent simple excision. Forty patients had conjunctival autografts. The recurrence rates estimated at 1 year were 40% and 16%, respectively (P= .031). In both groups, patients who were 50 years old or younger were more likely to have a recurrence (P = .029). All 23 patients with recurrent pterygium had conjunctival grafts, and the estimation of recurrence at 1 year was 25%. No serious complications occurred in any group. * CONCLUSION: Conjunctival autograft decreases the recurrence rate for primary pterygium compared with simple excision