Faculty Bibliography

OBJECTIVES: To determine the outcome and refractive status after triple and nonsimultaneous procedures for Fuchs' endothelial dystrophy and cataract. DESIGN: Records of 236 patients with Fuchs' endothelial dystrophy who were examined during 1988 were reviewed retrospectively. SUBJECTS: Group 1 consisted of 93 patients who had triple procedures (penetrating keratoplasty, extracapsular cataract extraction, and posterior chamber intraocular lens implantation); group 2 consisted of 32 patients who had nonsimultaneous procedures (penetrating keratoplasty followed by extracapsular cataract extraction and posterior chamber intraocular lens implantation). Variables in the first eye that had surgery for each patient were compared between the groups by means of unpaired t tests and Fisher's exact test. RESULTS: Mean follow-up after undergoing transplantation was 6 years in group 1 and 8 years in group 2. Clear grafts were obtained in 89 (96%) of eyes of group 1 and in 29 (91%) of eyes in group 2 (P = .37). A best-corrected visual acuity of 20/40 or better was achieved in 60 (65%) of eyes in group 1 and in 21 (66%) of eyes in group 2. Refractive errors within 2 diopters of emmetropia were found in 37 (42%) of eyes in group 1 and in 15 (48%) of eyes in group 2 (P = .51). Mean refractive cylinder was 3.9 diopters in group 1 and 4.1 diopters in group 2 (P = .67). CONCLUSIONS: There was no statistically significant difference in the outcome and refractive status after triple and nonsimultaneous procedures. To avoid increased cost and delay in visual rehabilitation, we recommend a triple procedure for patients with Fuchs' endothelial dystrophy and visually significant cataracts

PURPOSE. The common occurrence of failed medical treatment in microbial keratitis led us to investigate this phenomenon. METHODS. We retrospectively reviewed all ulcers that presented to our department for 24 consecutive months. We classified each ulcer as either a therapeutic success or failure based on a precise definition of the response to initial antibiotic selection. We then analyzed multiple factors including: antibiotic selection, ophthalmic disease, ulcer characteristics, and management, to determine their significance in the success or failure in treating microbial keratitis. Complications were also examined. RESULTS. Important factors in failure were non-fortified antibiotics (P < 0.001), ocular surface disease (P = 0.0178) and outpatient management (P < 0.001). Large ulcers (P = 0.051) were of borderline significance. Sensitivity results reflect high sensitivity among successfully treated patients when appropriate antibiotics are chosen. CONCLUSIONS. This report provides insight into current practice patterns and potential means to improve success in managing microbial keratitis

PURPOSE: We evaluated long-term corneal topographic stability and the safety of contact lens use after penetrating keratoplasty (PK). METHODS: Over a period of 3 years, we followed 18 patients who had been fit with rigid gas permeable (RGP) contact lenses after PK on the basis of computerized topographic measurements 1.5 mm superior to the visual axis. Computerized corneal topography, keratometry, refraction, visual acuity, slit-lamp examination, and contact lens parameters were recorded at the time of lens fitting and at 3 years follow-up. Comparison between the two times was performed using the paired Student's t test. The ten patients (55.5%) that did not undergo suture removal after initial contact lens fitting and who did not change contact lens type during the follow-up period were considered eligible for topographic and keratometric evaluation. RESULTS: Absolute keratometric astigmatism, average keratometric values, computerized corneal topography measurements 1.5 mm superior to the visual axis, and inferior minus superior measurements did not reveal significant differences over time. Keratometric vector analysis showed a significant change in astigmatism during the study period. Complications observed in the 18 patients included suture infiltrates (two patients), corneal neovascularization (six patients), graft rejection (five patients), transitory punctate epithelial keratitis (eight patients), and giant papillary conjunctivitis (three patients). All were successfully treated topically and with temporary cessation of contact lens wear. CONCLUSIONS: RGP contact lens use after PK is safe provided patients are properly fit and followed by the ophthalmologist. Although corneal topographic changes occur, stability remains acceptable

OBJECTIVE: To determine the graft survival, visual outcome, complications, and frequency of subsequent cataract extraction after penetrating keratoplasty for Fuchs' dystrophy. DESIGN: The medical records of 236 patients with the diagnosis of Fuchs' dystrophy who were examined on the Cornea Service at Wills Eye Hospital, Philadelphia, Pa, between January 1, 1988, were reviewed retrospectively. SUBJECTS: Penetrating keratoplasties had been or were subsequently performed on 130 phakic eyes of the 236 patients with Fuchs' dystrophy. Results were analyzed in 126 eyes with at least 1 year of follow-up. Statistical analysis was done to determine the risk factors for subsequent cataract surgery in the first eye of patients who had penetrating keratoplasty as their initial surgical procedure. RESULTS: Mean +/- SD follow-up after transplantation was 8.4 +/- 4.8 years. The graft remained clear in 112 eyes (89%). A best corrected acuity of 20/40 or better was achieved in 81 eyes (64%). Graft rejection occurred in 37 eyes (29%). Subsequent cataract surgery was performed in 55 eyes (44%), and the mean time from transplantation was 3.5 +/- 3.4 years. Advanced age at the time of transplantation was a significant risk factor for having cataract extraction (P = .003, Mantel-Haenszel chi 2 test) and a shorter time to cataract surgery after penetrating keratoplasty (P = .04, Mantel-Haenszel chi 2 test). Pregraft lens status approached significance as a risk factor for subsequent cataract surgery (P = .07, Mantel-Haenszel chi 2 test). CONCLUSIONS: Long-term results are favorable after penetrating keratoplasty for Fuchs' dystrophy. In older patients with Fuchs' dystrophy and mild-to-moderate lens changes, combines penetrating keratoplasty, cataract extraction, and intraocular lens implantation procedure should be considered

Objective: To assess the benefit of adding oral acyclovir to a regimen of topical prednisolone phosphate and trifluridine for the treatment of iridocyclitis caused by herpes simplex virus (HSV). Methods: Patients with HSV iridocyclitis were enrolled in a multicenter controlled clinical trial supported by the National Eye Institute, Bethesda, Md, and randomly assigned to receive a 10-week course of either oral acyclovir, 400 mg, 5 times daily, or oral placebo in conjunction with regimens of topical trifluridine and a topical corticosteroid. Follow-up examinations were performed weekly during the 10-week treatment period, every 2 weeks for an additional 6 weeks, and at 26 weeks after enrollment in the trial. Treatment failure was defined as a persistence or worsening of ocular inflammation, withdrawal of medication because of toxicity, or a request by the patient to withdraw from the trial for any reason. The trial was stopped because of slow recruitment after only 50 of the originally planned 104 patients were enrolled in more than 4 years. Results: A treatment failure occurred in 11 (50%) of the 22 patients in the acyclovir-treated group and in 19 (68%) of the 28 patients in the placebo group. Compared with the placebo group, the adjusted rate ratio for a treatment failure in the acyclovir-treated group during the 10-week treatment period was 0.43 (90% confidence interval, 0.18-1.02; P=.06, 1-tailed) and during the 16-week follow-up period (10-week treatment period plus 6-week observation period) was 0.60 (90% confidence interval, 0.29-1.25; P=.13, 1-tailed in a proportional hazards model). The treatment effect seemed slightly greater when only the patients with a persistence or worsening of ocular HSV disease were considered as treatment failures tie, excludes terminations because of toxic effects of the drug and patients who requested to withdraw from the trial). By life-table analysis, similar results were obtained; the possible benefit of acyclovir became apparent after the first 3 weeks of follow-up. Conclusion: While the number of patients recruited in this trial was too small To achieve statistically conclusive results, the trend in the results suggests a benefit of oral acyclovir in the treatment of HSV iridocyclitis in patients receiving topical corticosteroids and trifluridine prophylaxis. $$: