Faculty Bibliography

PURPOSE: To assess the patient characteristics, risk factors, and outcomes of penetrating keratoplasty wound dehiscence. METHODS: Retrospective chart review of 30 eyes of 29 patients with corneal grafts who underwent repair of penetrating keratoplasty wound dehiscence from January 1, 1998 to December 31, 2003, followed on the Cornea Service at Wills Eye Hospital. RESULTS: The mean time from penetrating keratoplasty to wound dehiscence was 7.5 years (range 1 week to 31 years). The mean age at time of wound dehiscence was 66 years (range 28-98 years). One eye developed wound dehiscence following suture removal, whereas the remaining 29 eyes sustained trauma-induced dehiscences. Falls were the most common mechanism of trauma, especially in the elderly population. There was a wide range of visual outcomes in the 21 patients followed for 1 year, with 4 patients maintaining best corrected visual acuity between 20/20 and 20/40 and 5 patients with light perception vision at 1 year. There were no cases of endophthalmitis. CONCLUSIONS: Patients with corneal transplants have a life-long risk for wound dehiscence. This complication may be reduced by the regular use of eye protection in all corneal transplantation patients

PURPOSE: To discuss the role of voriconazole in the management of Alternaria keratitis. METHODS: Case report and literature review. RESULTS: A 69-year-old man with a history of corneal foreign body removal developed a stromal infiltrate 2 months later that did not improve despite topical antibiotics and natamycin. On our initial examination, visual acuity (VA) was 20/40, and he had a central, full-thickness, reticular appearing infiltrate. Oral clarithromycin was added because of the atypical pattern of the infiltrate. However, no improvement was noted. A repeat culture revealed coagulase-negative Staphylococcus. VA decreased to 20/200, and increased inflammation was noted a month later; a trial of topical steroids was added. After an initial improvement, he returned with progression. Repeat culture revealed Alternaria species, and topical amphotericin was started. When there was no response, he was admitted and switched to oral and topical voriconazole. Steady resolution was noted within 10 days of therapy. CONCLUSION: Suspicion must be maintained for unusual causes of infectious keratitis. Fungal infection can be difficult to eradicate even with traditional antifungals. Although not approved for ophthalmic use yet, voriconazole provided improvement with Alternaria keratitis unresponsive to amphotericin

PURPOSE: To discuss the results of fitting Dyna Intra-Limbal lenses (Lens Dynamics, Inc., Golden, CO) (DIL) for pellucid marginal degeneration (PMD), keratoconus, and after penetrating keratoplasty (PK). METHODS: The charts of patients fitted with DILs between January 2003 and December 2004 were retrospectively reviewed. Ocular diagnosis, indication for DIL, flat and steep curvatures by corneal topography, and age at the time of initial fitting were noted. The DIL data included initial base curve, power, and the number of changes made in parameters during the follow-up. The outcome data included visual acuity and the duration of follow-up and lens wear. Complications and complaints were also noted. RESULTS: Twenty-seven eyes of 22 patients were reviewed. Fourteen eyes had PMD; seven had keratoconus; and six eyes had undergone PK. The mean age of patients was 52.7 +/- 13.1 years. The mean follow-up was 8.9 +/- 7.4 months. Nine (33.3%) eyes achieved 20/20 visual acuity; 13 (48.1%) eyes achieved 20/25 to 20/40; and five (18.5%) eyes achieved 20/50 to 20/70. Fifteen (55.6%) eyes achieved visual improvement (two lines or more). The mean number of refits was 1.1 +/- 0.9. No infection or neovascularization was noted; a corneal abrasion occurred in one eye. Good wearing time was achieved in 18 (66.7%) eyes of 13 patients, who were still wearing DILs at the last follow-up. CONCLUSIONS: DILs may be a good alternative in selected patients with flat central and superior corneas and inferior peripheral steepening

PURPOSE: To determine the characteristics of patients with anterior scleritis at a tertiary care eye center and determine which factors in these patients were associated with the need for systemic immunosuppressive therapy. PATIENTS AND METHODS: Retrospective study. Fifty patients with anterior scleritis presenting to the Cornea Service at Wills Eye Hospital from August 1996 to August 2001 were reviewed and divided into two groups. The control group included 35 patients who responded to oral non-steroid anti-inflammatory drugs (NSAIDs) and/or systemic steroids. The study group consisted of 15 patients who required additional treatment with systemic immunosuppressive agents. The influence of demographics, type of scleritis, bilateral disease, and ocular complications were analyzed. The presence of a systemic autoimmune disease, the best corrected visual acuity (BCVA), medications, and complications related to treatment were recorded. The statistical significance was evaluated by Student's t test for independence samples and Fisher's exact test; P<0.05 was considered significant. RESULTS: After a mean follow-up of 19.3 +/- 24.9 months, an associated systemic autoimmune disease was present in 17 patients (34%). Scleritis was the first manifestation of the systemic disease in 10 out of 17 patients (59%). Patients who required immunosuppressive treatment had more frequent ocular complications (80% versus 26%, P=0.0004) than did patients who responded to oral NSAIDs and/or steroids. CONCLUSIONS: Scleritis may be the sign of presentation of a systemic autoimmune disease. The presence of ocular complications, in particular corneal involvement, may be associated with the need for systemic immunosuppressive therapy

OBJECTIVE: To evaluate the incidence, history, symptoms, clinical signs, and treatment outcomes of blepharokeratoconjunctivitis in a pediatric population at a tertiary cornea practice. METHODS: In a retrospective case series, we reviewed the medical records of all new pediatric patients from January 1, 1997, through December 31, 2002, noting the reason for referral and subsequent diagnosis. We further noted the history, clinical characteristics, and treatment outcomes of the patients with blepharokeratoconjunctivitis. RESULTS: Review of 195 medical records revealed that blepharokeratoconjunctivitis was the most common single diagnosis at consultation, accounting for 15% of referrals. Of the 29 cases identified, there were 16 girls (55%) and 13 boys (45%). The mean age at consultation was 6(1/2) years (age range, 2-12 years). On initial ophthalmologic examination, 11 (38%) of 29 patients were taking full-strength steroids and 4 patients (14%) were taking oral erythromycin. Oral therapy, in the form of erythromycin (n = 21) and doxycycline (n = 1), was prescribed to most patients (22/29 [76%]). Therapy with topical steroids was tapered at the initial visit in all patients. Follow-up was available for 15 of 29 patients, with a mean follow-up of 5.4 months (range, 2-25 months). The condition of all patients showed clinical improvement. Recurrences were noted in 6 (40%) or 15 patients; all were successfully managed with low-potency steroid therapy. CONCLUSIONS: Blepharokeratoconjunctivitis is a common reason for cornea referral in children. Oral erythromycin therapy is an effective treatment with a steroid-sparing effect. Recurrences are common and may be successfully managed with low-potency steroid therapy

PURPOSE: To study the clinical and microbiological profile of Serratia corneal ulcers at the Cornea Service of the Wills Eye Hospital. METHODS: This was a retrospective, observational case series. The clinical records of patients with Serratia marcescens corneal ulcers seen at the Cornea Service of the Wills Eye Hospital between January 1, 1998 and December 31, 2002 were reviewed. RESULTS: Twenty-four cases of Serratia keratitis were identified in 21 patients. Two patients (9.5%) had recurrent keratitis, 1 of which recurred twice. Both had corneal graft edema and were on topical steroids and antiglaucoma drops. The Serratia infection in 15 patients (71%) was associated with an abnormal corneal surface. Twelve of these patients (57%) had the ulcer in a corneal graft, 4 (19%) of which were associated with suture infiltrates. Fifteen patients (71%) were on topical medications-15 used corticosteroids and 13 used antiglaucoma drops. Six patients (29%) were contact lens wearers-1 had a concomitant suture infiltrate associated with a corneal graft, and 5 had otherwise healthy corneas. One isolate lacked in vitro susceptibility to ciprofloxacin and ofloxacin but was susceptible to gentamicin and tobramycin. Nineteen patients had a favorable response to medical therapy. Two patients with poor outcome had large corneal ulcers with severe necrosis and thinning associated with delay in treatment. CONCLUSIONS: Serratia marcescens keratitis is associated with the presence of an abnormal corneal surface, use of topical medications, and contact lens wear. Prompt medical therapy results in a good clinical response in the majority of cases

PURPOSE: To determine the outcome of patients with decreased vision associated with anterior basement membrane dystrophy (ABMD) managed with diamond burr (DB) polishing. DESIGN: Retrospective nonrandomized case series. METHODS: A chart review of all patients with ABMD who underwent epithelial debridement and DB polishing to treat visual disturbances resulting from corneal epithelial irregularity was performed. RESULTS: Ten patients' charts were analyzed. The mean age was 57.4 years. DB treatment was performed in 13 eyes. The average preoperative BCVA was 0.40 (20/50). At the last follow-up (mean 21.8 months) the average visual acuity of these patients was 0.88 (20/23), significantly better than pre-operative readings (P < .001). There was no recurrence of dystrophic changes in the treatment zone seen with the slit lamp during the follow-up period. CONCLUSIONS: In this study, DB polishing was shown to be an effective and safe treatment for decreased vision caused by to ABMD over an average follow-up of 21.8 months

PURPOSE: This study was designed to determine how patients with pellucid marginal corneal degeneration (PMCD) are managed in a tertiary corneal practice. METHODS: A retrospective chart review of 45 patients with PMCD from a corneal referral practice was performed. Information collected from the medical records included demographic data, best-corrected visual acuity, videokeratography, contact lens use, and surgical procedures. RESULTS: Forty-five patients (85 eyes; 30 males, 15 females) with PMCD were included in this study. They were followed-up for an average of 4.7 years (standard deviation (SD), +/-8.7). Seventy-five eyes (88.2%) were managed nonsurgically with spectacles in 31 eyes (36.4%) or contact lenses in 44 eyes (51.8%). Contact lens management was initially attempted in 51 eyes (60%); however, 7 eyes failed contact lenses. Visual acuity of 0.5 (20/40) or better was noted in 34 eyes (75.5%) after contact lens fit. Ten eyes (11.8%) underwent penetrating keratoplasty with an average postoperative follow-up of 9 years (SD, +/-8.2; 1.5-20.5). Clear grafts were present in all 10 eyes at the end of the study (average, 9 years; SD, +/-82). CONCLUSIONS: Nonsurgical management of PMCD continues to play a predominant role in the management of this disorder. Poor best-corrected visual acuity at presentation of 0.2 (20/100) or worse and long follow-up (8 years or more) were significantly associated with surgery