Epidemiology and Outcome of Microbial Keratitis: Private University Versus Urban Public Hospital Care.

PURPOSE: To review the epidemiology, risk factors, microbiologic spectrum, and treatment of microbial keratitis during a 5-year period at an urban public hospital in comparison with an adjacent private university practice. METHODS: Retrospective chart review in the 5-year interval, 2009 through 2014. Primary outcome measures included patient age at presentation, best-corrected visual acuity (BCVA), risk factors, culture and sensitivities, treatment, and complication occurrence. RESULTS: A total of 528 eyes with microbial keratitis were identified, 318 in the public cohort and 210 in the private cohort. Contact lens wear was the most common risk factor in the public cohort, whereas ocular surface disease was the most common risk factor in the private cohort. Gram-positive organisms represented 47.3%, gram-negative organisms 32.1%, fungal organisms 13.6%, and Acanthamoeba 6.4% of corneal isolates. Gentamicin resistance was 4.4% and tobramycin resistance was 2.9%. The inpatient treatment rate of the public cohort was 40% compared with 4% in the private cohort. In the public cohort, average BCVA at resolution was 20/82 (log of minimal angle of resolution [logMAR] 0.61). For the private cohort, average BCVA at resolution was 20/73 [logMAR, 0.56]. The perforation rate was 8% in the public cohort compared with 4% in the private cohort. Six percent of cases underwent urgent penetrating keratoplasty in the public cohort versus 2% in the private cohort. CONCLUSIONS: Microbial keratitis remains a clinical challenge in the urban public hospital setting. The risk profile of patients presenting in the public hospital setting may be different from patients presenting in a private care setting. Public hospital patients may present later in the course of their infection and thus have a higher rate of complications regardless of effective antimicrobial therapy.

Corneal Pseudodendritic Lesions Masquerading as Herpetic Keratitis in a Patient With Tyrosinemia Type I.

OBJECTIVE: To describe the clinical findings of a patient with tyrosinemia type I with noncompliance to a protein-restricted diet, treated with 2-(2-nitro-4-trifluoromethylbenzoyl)-1,3-cyclohexanedione (NTBC). METHODS: Clinical findings at the initial examination and after strict compliance to a protein-restricted diet after 4 weeks follow-up are described in a patient with tyrosinemia type I on NTBC treatment, who had been treated with presumed herpetic keratitis. RESULTS: A 10-year-old girl diagnosed with hereditary tyrosinemia type I and on NTBC treatment presented with photophobia and ocular discomfort in both eyes. An ophthalmologic examination demonstrated bilateral dendritiform epithelial lesions in the central cornea, staining faintly with fluorescein. These lesions were subsequently intermittently treated with topical antivirals for presumed herpes simplex virus keratitis and lubricant eye drops for 9 months without resolution; however, when strict compliance with a protein-restricted diet was instituted, nearly a complete resolution of the lesions was noted at the 4-week follow-up. CONCLUSIONS: Although type II tyrosinemia is known to have corneal involvement, the natural course of tyrosinemia type I has not been shown to have corneal involvement. Corneal involvement in type I tyrosinemia may be an indicator of dietary noncompliance and may show complete resolution with a strict compliance to protein-restricted diet only.

Effects of a contact lens subscriber replacement program on patient lens care behavior in Japan.

PURPOSE: Compliance with practitioner recommended lens care guidelines was assessed and compared in two test groups: patients belonging to a subscription membership group and a nonaffiliated group of 2-week frequent replacement (2WFR) soft contact lens wearers. METHODS: Wearers (143 members and 149 nonmembers), whose clinical records were available for 18-24 months from September 2010 to August 2012, were queried by a written questionnaire: (1) source of lens purchase; (2) "rub" or "no-rub" care solution; (3) replacement interval of lens care products; (4) lens cleaning method; (5) noncompliant behaviors; and (6) replacement frequency of lens storage cases. RESULTS: The questionnaires were completed by 104 members and 100 nonmembers. Of member group wearers, 63.0% correctly recognized the types of lens care products used ("rub', "no-rub") vs. 77.4% of nonmembers. Of member wearers, 82.2% used "rub" and rubbed each time vs. 76.3% of nonmembers. The replacement interval for care products was 26.2% (members) and 27.6% (nonmembers) for 1 month or less, while replacement frequency of storage cases was 22.3% and 19.2% for 1 month or less in each group respectively. There were no significant differences observed between each of these group comparisons (p>0.05, Fisher exact test). CONCLUSIONS: Compliance with practitioner recommended lens care regimens was equally poor in both test groups. Subscription membership of CLs which does not provide lens care products is not accompanied by an increase in compliance with lens care practices.

Improvement of Subjective Symptoms and Eye Complications When Changing From 2-Week Frequent Replacement to Daily Disposable Contact Lenses in a Subscriber Membership System.

PURPOSE: Subjective symptoms and other eye complications were assessed and retrospectively compared in patients belonging to a proprietary membership system who switched from 2-week frequent replacement (2WFR) wear to daily disposable (DD) lens use. METHODS: Questionnaire responses were completed by all patients for a 5-year interval between October 2008 and September 2013 from 83 wearers in three Japanese clinics (59 female and 24 male; average age: 33.4±10.9 years). Complications were recorded for each patient at times of reexamination. RESULTS: Over the 5-year observation period, the 83 patients wore lenses for more than 26 months. The average duration of use of 2WFR lenses was 14.5±2.7 days/lens (n=83) and subsequently 1.03±0.12 days/lens (n=83) for DD lenses. Compliance with the duration of use was consistently good as monitored by requests for lens resupply in both wearing modalities. The subjective complaint of dryness tended to consistently show improvement by the change to DD wear: 18.1% vs. 30.1% (P=0.10, Fisher exact test). Among eye complications noted in each group, the occurrence of superficial punctate keratitis (SPK) was significantly decreased in DD wear: 9.6% vs. 26.5% (P=0.008, Fisher exact test). The main reasons given by patients for changing to DD wear were (1) "DD lens wear was more hygienic" (78.6%) and (2) "DD lens use is more convenient for travel/business trips" (64.3%). Comments after the switch in wear were (1) "easy and convenient" (95.7%) and (2) "I don't have to worry about expiration dates" on solutions (57.1%). Overall, 95.7% of wearers making the change answered as "satisfied" and "mostly satisfied." CONCLUSIONS: In the subscription membership program, which provided free lens replacement and/or reexamination, individual compliance with duration of wear in 2WFR wear cycles was good; however, these patients switching to DD wear tended to have improvement in their subjective complaints of dryness and objectively demonstrated a significant reduction of SPK at follow-up examinations.

Impact of Donor Age on Corneal Endothelium-Descemet Membrane Layer Scroll Formation.

OBJECTIVE: To correlate corneal endothelium-Descemet membrane (EDM) layer parameters of scroll tightness with donor age, endothelial cell density (ECD), and history of diabetes. METHODS: Endothelium-Descemet membrane layer scrolls were harvested from 26 corneoscleral buttons using the SCUBA technique by a cornea-fellowship trained ophthalmologist masked to donor age. Two independent outcome parameters were used to characterize the scrolling severity of successfully harvested tissue: scroll width and tendency for EDM scroll formation (referred to as scroll rating on a 1-4 scale: incomplete scroll formation to tightly scrolled). RESULTS: Mean donor age was 59 ± 17 (15-69) years. Mean ECD of EDM scroll was 2,451 ± 626 (range: 1,307-3,195) cells per square millimeter. Using stepwise linear regression, a significant correlation was found between scroll width and donor age (R=0.497, P<0.05). Additionally, a significant inverse correlation was found between scroll width and ECD (R=-0.605, P<0.05). There was no statistically significant correlation between a donor history of diabetes and the parameters of scrolling tendency. CONCLUSIONS: Our data suggest that using older donors reduces EDM scroll tightness.

Microbial Keratitis at an Urban Public Hospital: A 10-Year Update.

PURPOSE: To review the epidemiology, risk factors, microbiologic spectrum, and treatment of microbial keratitis during a five-year period at an urban public hospital with comparison to similar findings a decade earlier at the same hospital. METHODS: Retrospective chart review in the 5-year interval 2009 through 2014 compared to previously reported cases 2000 through 2004 [Eye & Contact Lens 33(1): 45-49, 2007]. Comparative primary outcome measures included best-corrected visual acuity (BCVA), risk factors, culture and sensitivities, treatment, and complication rates. RESULTS: 318 eyes with microbial keratitis were identified. Contact lens wear, ocular trauma, and ocular surface diseases were the most common risk factors. The culture and recovery rates were 73% and 66% respectively. Gram-positive organisms represented 46%, gram-negative organisms 39%, fungal organisms 15%, and Acanthamoeba <1% of corneal isolates. No common corneal pathogens were resistant to aminoglycosides or vancomycin. 48% of cases were initially treated with fortified antibiotics, 43% with fluoroquinolone monotherapy, and 6% with antifungals. 40% of cases received inpatient treatment. At resolution, average BCVA was 20/82 [logMAR 0.61] with 8% of cases resulting in light perception or worse vision. The perforation rate was 8%. 6% of cases underwent urgent penetrating keratoplasty and 4% of cases underwent urgent enucleation or evisceration. Compared to the prior study, significant differences were: (1) lower culture but higher recovery rates, (2) lower admission rate, (3) more contact lens-related cases of Pseudomonas ulcers, (4) lower resistance of coagulase-negative Staphylococcus to aminoglycoside antibiotics, (5) improved BCVA at resolution, and (6) lower associated complication rates. CONCLUSION: Microbial keratitis remains a clinical challenge in the urban public hospital setting. In the past ten years, epidemiology has shifted towards greater contact lens wear with more Pseudomonal infections. Visual outcomes have not worsened despite a shift away from routine culture and inpatient care to fluoroquinolone monotherapy and outpatient management.

Compliance study of contact lens wearers in Japan--part 2: evaluation of a subscribed membership system.

OBJECTIVE: To examine the hypothesis that membership in a contact lens (CL) supply system is associated with better compliance for regular wearers (members) who belong to the subscription membership system. METHODS: Subjects were 104 members and 100 nonmember wearers of 2-week frequent replacement silicone hydrogel CLs whose clinical information was retrospectively available for 1.5 to 2 years in the interval between September 2010 and August 2012. The average duration of use of a single lens was calculated from the number of lenses supplied during the observation period and surveyed using questionnaires. Subjective symptoms and eye complications were also documented and compared. RESULTS: The average duration of use of a lens was significantly longer in nonmembers (17.8±5.6 days/lens; n=91) than in members (14.2±3.5 days/lens; n=98) (P<0.001, Mann-Whitney U test). The number of wearers who replaced their lenses within 15.4 days per lens wear was significantly higher in members (74.5%) as compared with nonmembers (45.1%) (P<0.001, Fisher exact test). Levels of compliance reported by wearers did not match with those indicated in clinical records. In recorded eye complications, the rate of incidence of allergic and giant papillary conjunctivitis tended to be higher in nonmembers as compared with members. CONCLUSIONS: The hypothesis that a membership system could be associated with better compliance was found to be supported by clinical records. It is suggested that a membership system is useful for identifying wearers who want to be more compliant and that better compliance may reduce long-term complications of lens wear.

Compliance study of contact lens wearers in Japan, part 1: internet survey of actual circumstances of lens use.

PURPOSE: To conduct a survey of contact lens (CL) wearers who use their CLs with satisfaction in Japan and to establish the actual circumstances of CL use. METHOD: An Internet survey was conducted in 1,000 CL wearers in Japan with questionnaires concerning CL purchase/change, compliance with the duration of wear, and occurrence of complications of CL use. RESULTS: Replies from 636 women (63.6%) and 364 men (36.4%) were received. The largest source of CL purchase was CL specialty stores (eyeglass chains, 41.3%). The most frequent CL types were 2-week frequent replacement (2WFR) soft CLs (SCLs) (32.1%), daily disposable (DD) (31.0%), and other lenses. The main determining factors of purchase were "price" (38.0%), "recommendation of a doctor/staff" (37.6%), and "comfort" (34.1%). The number of wearers who changed their CLs was 372 (37.2%), and the main reasons for change were "inexpensive" (34.9%) and "recommendation of a doctor/staff" (31.2%). In DD and 2WFR/planed replacement SCLs, 270 (42.7%) of 632 wearers were compliant with the recommended duration of use, and the remainder were self-identified as noncompliant. The main reason given for noncompliant behavior was "no harm in extending the duration of use" (60.3%). The number of wearers with eye complications related to lens was 373 (37.3%). CONCLUSIONS: The choice of CLs by wearers seems to be price driven rather than being safety focused. Despite being aware of noncompliant behaviors regarding CL use, there were many noncompliant wearers. Clearly, ophthalmologists, optometrists, CL manufacturers, and other CL-related practitioners should cooperate and better educate patients to promote the importance of compliance with safe lens use.

Comparison of hepatitis B, core, HBc, and hepatitis B antibody, anti HBs, in a presumed low risk donor population.

Donors screened by medical social history interview negative for high risk behavior or communicable disease history, but subsequently exhibiting reactive serological markers, emphasize importance of duel safe guarding factors for determining donor suitability. This report examines a relationship between two immunoabsorption assay tests, hepatitis B core (HBc) antibody, a required food and drug administration (FDA) test, and hepatitis B antibody (anti HBs), non-required test. Reactive serology results, 129 cases, 3,581 donors (2008-2012) for HBc as the only initially positive serological marker were subjected to anti HBs testing in this history pre-screened donor population. Enzyme linked immunoabsorption assay kits hepatitis B, core and antibody, were used in this study. All samples were initially tested for human immunodeficiency virus, hepatitis B, and hepatitis C, utilizing nucleic acid testing and antigen antibody immunoabsorption assay. Testing was performed by a FDA-registered CLEA-certified reference laboratory. Samples were deceased donor blood samples and a limited number of pre-mortem samples, separated, stored and analyzed according to manufacturer recommendation and FDA regulations. 129 reactive HBc only samples, were subsequently tested for anti HBs. Of these 129, 94 were found to be reactive for anti HBs. This represented 72 % of samples tested for antibody, a higher percentage than anticipated for a medical history negative, low risk population.

Contact lens care solutions downregulate membrane-associated mucins 1 and 16 in cultured human corneal epithelial cells and at the rat corneal surface in vivo.

OBJECTIVE: The purpose of this study was first to evaluate the effect of multipurpose contact lens care solutions (MPSs) on the expression of membrane-associated mucins (MUC1 and MUC16) in SV40-transformed human corneal epithelial (HCE-T) cells and in vivo rat cornea. The second aim of this study was to determine the role of the common MPS additive boric acid in reducing mucin expression and release. METHODS: The HCE-T cells were exposed to different concentrations of MPS-F, MPS-G, MPS-H, MPS-I, and MPS-J with 100% treatment for 30 minutes and 10% treatment for 24 hours. MUC1 and MUC16 expressions were subsequently analyzed by Western blotting. Wister rats were also subjected to MPS-A, MPS-B, MPS-C, MPS-D, and MPS-E and received phosphate-buffered saline exposure (1 drop in the right eye every 10 minutes for 1 hour). The left eye was used as control. Cornea sections and lysates were used for the immunohistochemical assay of MUC1 and MUC16 expressions. Conditioned media from treated HCE-T cells were also analyzed using Western blotting. RESULTS: The MPSs containing boric acid downregulated MUC1 and MUC16 in the rat cornea, whereas MPSs without boric acid had no effect as demonstrated by the Western blotting and immunohistochemical analysis. Conditioned media from MPS-containing boric acid revealed some trace of MUC16. CONCLUSIONS: The clinical use of MPSs containing boric acid that reduce MUC1 and MUC16 availability should be avoided. Additionally, the presence of MUC16 in the conditioned media suggests that boric acid may have enhanced cleavage of MUC16 at the cell membrane surface.

Epidemiology and characteristics of childhood glaucoma: results from the Dallas Glaucoma Registry.

PURPOSE: Few studies have provided epidemiological characteristics of childhood glaucoma in a large, multiethnic population. This information is important if we are to better screen for and characterize this specific type of glaucoma. In this study, we evaluate the characteristics of patients with childhood glaucoma, including glaucoma suspects, as identified through the Dallas Glaucoma Registry (DGR). PATIENTS AND METHODS: The DGR catalogs the characteristics of glaucoma patients seen at University of Texas Southwestern Medical Center, an academic tertiary referral center for a large, multiethnic, urban population in the United States. We analyzed these patients with respect to race, medical and surgical treatment, cup-to-disc ratio, intraocular pressure, and visual outcomes. RESULTS: The study comprised 376 eyes of 239 childhood glaucoma patients, of whom 19% had primary congenital glaucoma, 4% had primary juvenile glaucoma, 45% had secondary glaucoma, and 31% were glaucoma suspects. Trauma and postsurgical aphakia were the most common causes for secondary glaucoma. Thirty-eight percent of patients were Hispanic, 30% were Caucasian, 21% were African American, 3% were Asian, and 9% were unknown or unreported. Male sex was more common at 56%. Of all eyes with glaucoma, 65% received surgical intervention while 70% required at least one medication for intraocular pressure control. Trabeculotomy and tube-shunt surgery were the most common surgeries performed. Of patients who could have Snellen visual acuity measured, glaucoma suspect eyes had the largest proportion of eyes (96%) with good visual acuity (better than 20/40) while primary congenital glaucoma eyes had the smallest proportion (41%) with good visual acuity. Secondary glaucoma eyes had the largest proportion of eyes (30%) with poor visual acuity (worse than count fingers). CONCLUSION: The most common etiologies of childhood glaucoma were primary congenital glaucoma and secondary causes including trauma and postsurgical aphakia. A high proportion of glaucoma patients were of Hispanic background, reflecting the patient population studied. Trabeculotomy and tube-shunt surgery were the most common surgical interventions performed.

Effects of multipurpose solutions on the viability and encystment of acanthamoeba determined by flow cytometry.

PURPOSE: To evaluate simultaneously the effects of multipurpose contact lens care solution (MPS) on the viability and encystment of Acanthamoeba using flow cytometry. METHODS: Viability and encystment rate were evaluated using Acanthamoeba castellanii (ATCC 50514 and ATCC 50370) and three clinical strains of Acanthamoeba spp. isolated from patients with Acanthamoeba keratitis. Acanthamoeba trophozoites (1.0 × 10(5) cells/mL) were exposed to four kinds of commercially available MPSs for 24 hours. After dispensing the cell suspension into two portions, one portion was stained with 0.004% Congo Red (CR), a fluorescence dye to stain the inner cell wall of cysts, and the other portion was stained with a mixture of Congo Red and 3% sarkosyl (CRS), a detergent to lyse the trophozoites and pseudocysts. Flow cytometric analysis of the treated portions was then carried out on an EPICS ALTRA flow cytometer. The encystment rate and disinfecting efficacies (percentage of rounded trophozoites, "pseudocyst") were calculated by the rates of CR-stained, CR-nonstained, and CRS-stained populations, respectively. Ultrastructural features of resistant (mature or immature) cysts and pseudocysts were observed by transmission electron microscopy. RESULTS: Resistant cysts and rounded trophozoites (pseudocysts) were stained with CR, whereas native (unrounded) trophozoites were not. Resistant cysts were also stained with CRS unlike pseudocysts. Three clinical isolates showed higher resistance and higher encystment rates than two ATCC strains when treated with encystment-positive control solution. Disinfecting efficacy of each MPS was not directly related to each encystment rate. Transmission electron microscopy observations showed basic differences in the ultrastructure of pseudocysts produced by MPSs and resistant cysts. CONCLUSIONS: These results suggest that viability and encystment of Acanthamoeba are independent phenomena, and therefore disinfecting efficacy of MPS and encystment rates of Acanthamoeba should be evaluated, respectively. Thus, it is important to evaluate simultaneously the disinfecting efficacies and encystment rates of newly developed premarket MPS using the authors' novel flow cytometric methods.

The accuracy of the double-K adjustment for third-generation intraocular lens calculation formulas in previous keratorefractive surgery eyes.

PURPOSE: To evaluate the effect of the double-K (DK) modification on third-generation formulas. METHODS: Thirty-eight previously myopic and 24 previously hyperopic eyes that underwent phacoemulsification with intraocular lens (IOL) insertion after Laser in situ keratomileusis (LASIK) were evaluated. Pre-LASIK refraction and keratometry, post-LASIK topography, axial length (AL), IOL type and power, and 1-month postphacoemulsification refraction were recorded spherical equivalent after phacoemulsification (SE(postphaco)). Measured corneal power was adjusted using published and validated methods for postmyopic and posthyperopic LASIK. For each eye, and using SE(postphaco), different DK-IOL formulas were used to calculate the corresponding IOL power, the outcome measure, which was compared with the implanted IOL. RESULTS: DK-Holladay 1 yielded the highest Pearson correlation coefficient (PCC), 0.955 for myopes and 0.943 for high myopes (AL>26 mm). Mean error (ME) and mean absolute error (MAE) for myopes for DK Sanders-Retzlaff-Kraff theoretical formula [DK-SRK/T] were 0.44±0.84 D and 0.75±0.61 D for DK-SRK/T compared with -0.04±0.67 D and 0.52±0.40 D for DK-Holladay 1 (P<0.001 and P=0.016, respectively), and 0.03±0.88 and 0.64±0.58 for DK-Hoffer Q. For high myopes, ME and MAE were 0.75±0.81 D and 0.84±0.69 D for DK-SRK/T, and -0.05±0.74 D (P<0.0001) and 0.57±0.45 D (P=0.019) for DK-Holladay 1. About 29% of DK-SRK/T eyes with large AL had MAE>1.5 D, compared with 0% for DK-Holladay 1 and 14% for DK-Hoffer-Q. Eyes with previous hyperopic LASIK faired similarly for all formulas, with similar PCCs, and only 8% in each category with MAE>1.5 D. CONCLUSIONS: DK-SRK/T overestimates IOL power in eyes with large AL, especially with concomitant steep pre-lasik keratometry. Among third-generation formulas, DK-Holladay 1 seems more accurate to use in postmyopic LASIK eyes.

Evaluation of diminished microbial contamination in handling of a novel daily disposable flat pack contact lens.

PURPOSE: To evaluate the efficacy of a novel daily disposable (DD) flat package in regard to microbial contamination on the anterior and posterior surfaces of a contact lens (CL) during handling of the lens for insertion. METHODS: Four kinds of commercially available general blister-packed daily disposable contact lenses (DD CLs) as controls and a novel Magic 1-day Menicon Flat Pack as a test lens were used for this in vitro study. Lenses were removed from their packages using fingers coated with fluorescein 3 to 5 µm beads or an approximately 7×10(2) to 2×10(3) colony-forming unit (CFU)/mL Staphylococcus aureus suspension. The transfer of fluorescein beads to the surface of the lenses was then observed by fluorescence microscopy. Microbial contamination on the lenses was observed by light microscopy after a 2-day incubation period; and, the number of colonies isolated from the contaminated lenses was determined after 4 days of incubation. RESULTS: The number of fluorescein beads on the Magic lens was significantly less (p<0.05) than that of the general blister-packed control lenses. Adherence of microbial colonies was observed on both inner and outer surfaces of general blister-packed lenses, whereas no colony formation was found on the inner surface of the Magic lens, and the lowest bacterial adherence was observed for the Magic lens. CONCLUSIONS: The data demonstrated that placement of the Magic DD lens onto the eye is accompanied by diminished microbial contamination compared with general blister-packed DD CLs. Eye care professionals; however, should instruct patients to comply with intended use of DD CLs to prevent CL-associated microbial keratitis. In all cases, hand washing is mandated prelens insertion.

Viral HCV RNA reactivity of corneal cells in plasma HCV nucleic acid-positive eye donors.

PURPOSE: Hepatitis C virus (HCV) infection is a worldwide health concern according to the World Health Organization, and a positive serology test for HCV is currently one of the most common reasons for tissue rejection for transplantation. Demonstrating the presence or absence of viral RNA or DNA in corneal cells, a privileged avascular site, verifies the importance of screening and testing protocols, which eliminate individual donor tissue from potential release for transplantation. METHODS: Improved tests such as nucleic acid test (NAT) have added a significant advantage in the arsenal of measures employed to determine donor eligibility. Standard testing for blood using nucleic acid technology was applied to aliquots of corneal cells obtained by scraping pooled epithelial and endothelial cells from individual donor corneas. RESULTS: Results of the current study further confirm and extend the importance of NAT blood tests by the demonstration of a high percentage (77%) of corneal cells that test positive with HCV NAT in conjunction with concomitant serum-positive ocular tissue donor samples. CONCLUSIONS: These data provide important support for Center for Disease Control and Prevention reports that state that 3 of 4 seropositive individuals were also viremic, and reemphasize the importance of routine NAT blood testing in assuring safe tissue transplants.

Sarnicola air-visco bubble technique in deep anterior lamellar keratoplasty.

PURPOSE: The purpose of this study was to describe a new modification for big-bubble deep anterior lamellar keratoplasty (DALK) using pneumatic pressure to detach Descemet membrane (DM) via air injection followed by ophthalmic viscoelastic device (OVD) injection. METHODS: After failure of big-bubble formation after air injection, OVD was injected from a different site other than the previous air injection using a 27-gauge cannula to detach DM, called air-visco bubble (AVB) DALK technique. The technique was used in 7 human corneoscleral rims that were investigated with anterior segment optical coherence tomography and histopathology and in 69 eyes that underwent DALK surgeries. RESULTS: Big-bubble formation was noted in 4 of 7 of the donor corneoscleral rims. The anterior segment optical coherence tomography showed big-bubble formations together with intrastromal OVD accumulation. The histology of the donor corneas showed microdetachments at the DM in the periphery, deep intrastromal separation, and big-bubble formation filled with OVD. One hundred forty-one of 210 eyes (67%) underwent successful DALK with only air injection, and 69 of 210 eyes (33%) underwent AVB technique when a big bubble was not achieved with only air injection. All the corneas showed a clear interface with good wound healing when DM was bared with the AVB DALK technique. CONCLUSIONS: Additional OVD injection to detach DM may be useful in cases where air injection fails. Also, creating small DM detachments with air injection may facilitate the formation of a big bubble with further OVD injection.

Nucleic acid testing and tissue safety: an eye bank's five-year review of HIV and hepatitis testing for donor corneas.

PURPOSE: Tissue safety and added testing is a frequent topic of discussion among those who must evaluate donor suitability and assure appropriate testing. Therefore, the purpose of this report was to examine the data of one eye bank (accredited by Eye Bank Association of America) for the presence or absence of reactive serology in 3592 donors over a 5-year period, from 2005 to 2010. METHODS: The number of specific analytes, human immunodeficiency virus (HIV), hepatitis B virus, or hepatitis C virus, that were reactive and the number of multireactive serologies are presented along with reports related to the identification of nucleic acid testing (NAT), NAT-reactive donors in correlation with other antigen or antibody markers. Antigen or antibody markers are enzyme-linked immunosorbent assay immunoassay kit determinations. NATs are used to measure the presence of RNA or DNA virus. RESULTS: The 249 donors with reactive serologies serve to confirm the importance of serologic testing in history-negative potential donors. Furthermore, the findings of 2 HIV NAT-only reactive individuals is significant because it may indicate an early unrecognized exposure and "window period" infectivity not recognized by antibody testing alone. These results support the appropriate inclusion of this added test to guarantee tissue safety. CONCLUSIONS: The finding of 2 potential donors without identified risk factors but with reactive HIV NAT suggests the need for comprehensive serologic testing in conjunction with medical social history screening. Considered together, screening and testing offer the best allograft tissue safety currently available.

Quantitative 3-dimensional corneal imaging in vivo using a modified HRT-RCM confocal microscope.

PURPOSE: The purpose of this study was to develop and test hardware and software modifications to allow quantitative full-thickness corneal imaging using the Heidelberg Retina Tomograph (HRT) Rostock Corneal Module. METHODS: A personal computer-controlled motor drive with positional feedback was integrated into the system to allow automated focusing through the entire cornea. The left eyes of 10 New Zealand white rabbits were scanned from endothelium to epithelium. Image sequences were read into a custom-developed program for depth calculation and measurement of sublayer thicknesses. Three-dimensional visualizations were also generated using Imaris. In 6 rabbits, stack images were registered, and depth-dependent counts of keratocyte nuclei were made using Metamorph. RESULTS: The mean epithelial and corneal thickness measured in the rabbit were 47 ± 5 µm and 373 ± 25 µm, respectively (n = 10 corneas); coefficients of variation for repeated scans were 8.2% and 2.1%. Corneal thickness measured using ultrasonic pachymetry was 374 + 17 µm. The mean overall keratocyte density measured in the rabbit was 43,246 ± 5603 cells per cubic millimeter in vivo (n = 6 corneas). There was a gradual decrease in keratocyte density from the anterior to posterior cornea (R = 0.99), consistent with previous data generated in vitro. CONCLUSION: This modified system allows high-resolution 3-dimensional image stacks to be collected from the full-thickness rabbit cornea in vivo. These data sets can be used for interactive visualization of corneal cell layers, measurement of sublayer thickness, and depth-dependent keratocyte density measurements. Overall, the modifications significantly expand the potential quantitative research applications of the HRT Rostock Cornea Module microscope.

Long-term outcomes of a pseudo 360-degree trabeculotomy ab externo technique for congenital glaucoma at children's medical center.

PURPOSE: To quantify the long-term outcomes of congenital glaucoma and surgical success rates following pseudo 360-degree trabeculotomy surgery at Children's Medical Center in Dallas. PATIENTS AND METHODS: An International Classification of Diseases (ICD-9) database was utilized for a retrospective chart review. Thirty-eight eyes of 24 who underwent primary trabeculotomy with a pseudo 360-degree technique between June 1, 1992 and December 31, 2005 were studied. RESULTS: Mean age at the time of trabeculotomy was 11.1 ± 3.0 months, with seven eyes operated on after 1 year of age. Mean follow-up was 85.1 ± 9.0 months. Mean intraocular pressure (IOP) at the time of glaucoma diagnosis was 32.7 ± 1.1 mmHg, and final mean IOP for all eyes (after trabeculotomy and any additional surgery and/or glaucoma medications) was 17.9 ± 0.8 mmHg. With trabeculotomy and medication alone, mean final IOP was 19.9 ± 1.1 mmHg, with a mean drop in IOP of 12.5 ± 1.4 mmHg. Surgical success, defined by adequate IOP control, was achieved in 30 eyes (78.96%) at most recent follow-up. Kaplan-Meier analysis demonstrated 5- and 10-year survival probabilities of 93.1% and 66.8%, respectively. Seventeen eyes (44.7% of all eyes) achieved complete success, meaning IOP control <21 mmHg without additional medical therapy. All seventeen had primary congenital glaucoma (PCG); no eyes with aphakic glaucoma (AG) or Sturge-Weber syndrome (SWS) achieved complete success. Seven eyes (18.4%) failed primary trabeculotomy. Mean time to failure was 46.9 ± 8.6 months. Eyes with SWS had a significantly higher failure rate (P = 0.009) and a 5.81 relative risk of failure (P = 0.026). CONCLUSIONS: Our long-term trabeculotomy success rates for congenital glaucoma compare favorably with existing reports in the literature. Eyes with AG and SWS may warrant consideration of alternative primary surgical methods, or closer postoperative surveillance.