Faculty Bibliography

PURPOSE: To identify current indications and trends in indications for penetrating keratoplasty (PKP) and associated procedures. METHODS: Retrospective chart review of all patients who underwent PKP at Wills Eye Institute from January 1, 2001, to December 31, 2005. RESULTS: A total of 1,162 cases were performed in this 5-year period. Leading indications for PKP were pseudophakic corneal edema (PCE) in 330 (28.4%) cases, followed by regraft in 250 (22.0%), keratoconus in 186 (16%), and Fuchs' endothelial dystrophy in 126 (10.8%) cases. Of the 330 cases of PCE, 232 (70.3%) were associated with posterior chamber intraocular lenses (PCIOLs) and 96 (29.1%) with anterior chamber lenses. In 330 eyes with PCE, the lens was not exchanged in 246 (74.5%) cases and was exchanged in 76 (23%) cases. Seventy of the exchanged lenses were anterior chamber intraocular lenses (ACIOLs) and six lenses were PCIOLs. In cases of ACIOL exchanges, 10 were for scleral sutured IOLs, 18 for PCIOLS, and 42 for another ACIOL. CONCLUSIONS: Pseudophakic corneal edema remains the leading indication for PKP at our institution followed by regraft, continuing a trend noted in our previous studies. Although the percentage of cases of PCE associated with PCIOLS increased, fewer lenses were exchanged, perhaps reflecting increased confidence in biocompatibility of newer IOLs. The decrease in overall number of corneal transplants in these 5 years continues a trend noted in our previous study and mirrors the national decline in PKP

In this review, we analyze the trends in corneal transplantation over the past 25 years in the United States. The most dramatic change was the progressive sharp increase in the number of corneal transplants performed during the 1980s, corresponding with the rise of pseudophakic bullous keratopathy (PBK) as the leading indication for keratoplasty. More recently, there has been a steady annual decline in total keratoplasties for more than a decade, corresponding with a decline in the cases performed for PBK, which still accounts for the highest percentage of cases done. Regrafts have been an increasingly important indication for keratoplasty, as older grafts fail. Keratoconus, Fuchs dystrophy, and other inherited diseases have remained consistent indications for keratoplasty during the last quarter century

PURPOSE: To assess the risk and incidence of rejection in patients who underwent bilateral penetrating keratoplasty (PK) and had at least one rejection episode. METHODS: The records of patients undergoing PK between January 1994 and December 2003 were retrospectively reviewed. Inclusion criteria were bilateral PKs and at least one rejection within 18 months of either PK. Exclusion criteria were PK performed elsewhere, multiple grafts in the same eye, and fewer than 18 months between PKs in the two eyes. RESULTS: Eighty-three patients had bilateral PKs (56 women and 27 men) at least 18 months apart and had a rejection episode within 18 months of at least one surgery. Their mean age was 57.1 +/- 17.7 years. The mean follow-up after the first and second PKs were 9.6 +/- 5.4 and 4.1 +/- 3.7 years, respectively. Kaplan-Meier survival analysis showed that PK in the second eye did not impose an increased risk of rejection in the first eye. There was no significant difference in the frequency of rejections between the two eyes during the first 18 months after the second PK. The first eye was significantly more likely to have a rejection during the first 18 months after the first PK than during the first 18 months after the second PK (P=0.01). CONCLUSIONS: Having a PK in the second eye does not impose a significantly increased risk of rejection for the first eye when PKs are performed at least 18 months apart. There is an indefinite risk for rejection. Lifelong regular follow-up and immediate evaluation for new symptoms are essential

PURPOSE: To report a rare case of bilateral and symmetric Meesmann corneal dystrophy concurrent with bilateral epithelial basement membrane dystrophy and bilateral but asymmetric posterior polymorphous corneal dystrophy in a patient of Armenian origin. METHODS: Complete ophthalmologic examination was performed on a 6-year-old boy from Armenia who was diagnosed with bilateral symmetric Meesmann corneal dystrophy combined with bilateral epithelial basement membrane dystrophy and bilateral but asymmetric posterior polymorphous corneal dystrophy. This case was observed and treated for 24 years. RESULTS: On slit-lamp biomicroscopy, the patient showed bilateral multiple intraepithelial cystic lesions, bilateral irregularly shaped grayish-white opacities in the superficial corneal epithelium, and bilateral but asymmetric transparent vesicles surrounded by gray halos at the level of the Descemet membrane and the endothelium. CONCLUSIONS: This case is reported because of the unusual occurrence of Meesmann corneal dystrophy with other corneal dystrophies

PURPOSE: To review the symptoms, findings, and management options in patients referred to the Cornea Service who were unsatisfied with results after laser in situ keratomileusis (LASIK). SETTING: Cornea Service, Wills Eye Institute, Philadelphia, Pennsylvania, USA. METHODS: A retrospective chart review was conducted of all patients seen for consultation between January 1, 2004, and December 31, 2006, who had LASIK performed elsewhere. The parameters extracted were demographic data, history, symptoms, postoperative best corrected and uncorrected visual acuities, surgical complications, examination findings, and treatment recommendations. The data were also compared with previously unpublished data collected at Wills Eye from 1998 to 2003. RESULTS: One hundred fifty-seven eyes of 109 patients seen in consultation after LASIK were identified. Twenty-eight percent were referred by the LASIK surgeon and 54%, by another eye doctor; 17% were self-referred. The most common chief complaints were poor distance vision (63%), dry eyes (19%), redness/pain (7%), and glare and halos (5%). Forty-four eyes (28%) had surgical complications or enhancements. The most common diagnoses were dry eye or blepharitis (27.8%), irregular astigmatism (12.1%), and epithelial ingrowth (9.1%). Eleven percent were referred in the first month after LASIK; 23% and 10% were referred between 1 and 6 months and 7 and 12 months, respectively. Medical management (eg, artificial tears, steroids, other dry-eye treatment) was offered in 39% of cases, surgical intervention in 27%, and observation only in 7%. Nonsurgical therapy was offered in 73% of cases. CONCLUSIONS: Most patients who came for consultation were referred by a doctor other than their LASIK surgeon. Poor distance vision, dry eye, redness/pain, and glare and halos were the most common chief complaints and dry eye or blepharitis, irregular astigmatism, and epithelial ingrowth, the most common diagnoses

PURPOSE: To report an outbreak of Fusarium keratitis in contact lens (CL) wearers in the northeastern United States. METHODS: Over a 41-month period, all cases with culture-proven corneal ulceration secondary to Fusarium at 2 tertiary care eye centers were identified through the microbiology departments of each institution, and a retrospective review of charts was performed. Statistical analyses were performed to evaluate a possible association of Fusarium keratitis with specific CL and CL solution brands. RESULTS: Fifteen cases of Fusarium keratitis were reported at the 2 tertiary centers between July 2005 and May 2006 (16.4 cases/yr) compared with 6 cases over the previous 30 months from January 2003 to June 2005 (2.4 cases/yr). All 15 of the more recent cases were CL users, and none had a history of trauma. All 15 patients claimed use of ReNu brand contact lens solution when they developed keratitis. Twelve (80.0%) of 15 patients were Acuvue soft contact lens users. Ten (66.7%) of 15 patients used tap water to rinse their contact lens cases. Six (40.0%) of 15 cases have thus far required corneal transplantation. CONCLUSIONS: The incidence of corneal ulceration secondary to Fusarium has increased sevenfold over the reported 11-month period at 2 tertiary eye care centers in the northeastern United States compared with the previous 30 months. There seems to be an association between the recent outbreak of Fusarium keratitis among CL users and the use of ReNu contact lens solution. Medical treatment of Fusarium keratitis may be ineffective, and emergent penetrating keratoplasty (PKP) may be required in some patients. CL users and their physicians should reconsider the risks of CL use and discuss proper lens care techniques

PURPOSE: To evaluate the visual and topographic outcomes in patients with keratoconus who have undergone cataract surgery and to analyze different methods of keratometry and formulas for intraocular lens (IOL) calculation in patients with keratoconus. METHODS: In a retrospective case series, 12 eyes (nine patients) with keratoconus underwent phacoemulsification with IOL implantation. The IOL power was determined by using standard and corneal topography-derived keratometry in three formulas: SRK, SRKII, and SRKT. Three months after surgery, best-corrected visual acuity (BCVA), visual improvement, simulated keratometry, and contact lens fit were assessed. Retrospectively, the difference between spherical equivalent and desired refraction was evaluated for the ideal IOL power. The difference between the ideal IOL power and the calculated IOL power from the three formulas was determined to evaluate the best formula for these patients. RESULTS: The mean age was 55 years (range, 38-76 years). All eyes had improved BCVA (mean of four lines). Of the five eyes with mild keratoconus, three were switched from rigid gas-permeable lens wear before surgery to soft toric contact lenses (n = 2) or spectacles (n = 1). Patients with moderate and severe keratoconus (7 of 12) still required rigid gas-permeable lenses after surgery. In mild keratoconus, there was no difference between standard and topography-derived keratometry. The most accurate IOL power was found by using SRKII. CONCLUSIONS: Cataract surgery can improve BCVA in all severities of keratoconus without significant corneal change. IOL calculation is more predictable in mild keratoconus than in moderate and severe disease

PURPOSE: We report 4 cases of corneal ulcers associated with drug abuse. The pathogenesis of these ulcers and management of these patients are also reviewed. METHODS: Review of all cases of corneal ulcers associated with drug abuse seen at our institution from July 2006 to December 2006. RESULTS: Four patients with corneal ulcers associated with crack cocaine use were reviewed. All corneal ulcers were cultured, and the patients were admitted to the hospital for intensive topical antibiotic treatment. Each patient received comprehensive health care, including medical and substance abuse consultations. Streptococcal organisms were found in 3 cases and Capnocytophaga and Brevibacterium casei in 1 patient. The infections responded to antibiotic treatment. Two patients needed a lateral tarsorrhaphy for persistent epithelial defects. CONCLUSIONS: Aerosolized crack cocaine use can be associated with the development of corneal ulcers. Drug abuse provides additional challenges for management. Not only treatment of their infections but also the overall poor health of the patients and increased risk of noncompliance need to be addressed. Comprehensive care may provide the patient the opportunity to discontinue their substance abuse, improve their overall health, and prevent future corneal complications