Case report of interstitial keratitis in pregnancy.

Purpose: To report an unusual case of interstitial keratitis and lipid keratopathy in a pregnant woman with unknown etiology and atypical clinical course. Observations: A 15 weeks pregnant 32-year-old female daily soft contact lens wearer presented with 1 month of right eye redness and intermittent blurry vision. Slit lamp examination revealed sectoral interstitial keratitis with stromal neovascularization and opacification. No underlying ocular or systemic etiology was identified. The corneal changes were unresponsive to treatment with topical steroids and progressed over the ensuing months of her pregnancy. On continued follow up, the cornea demonstrated spontaneous partial regression of the opacification in the post-partum period. Conclusions and importance: This case illustrates a possible rare manifestation of pregnancy physiology in the cornea. It also emphasizes the utility of close follow-up and conservative management in pregnant patients with idiopathic interstitial keratitis not only to avoid intervention during pregnancy but also because of the possibility of spontaneous improvement or resolution of the corneal changes.

Peripheral Hypertrophic Subepithelial Corneal Degeneration.

PURPOSE: The purpose of this study was to report a large series of patients with peripheral hypertrophic subepithelial corneal degeneration (PHSCD) and differentiate the condition from Salzmann nodular degeneration (SND). METHODS: We retrospectively reviewed the charts of 49 patients diagnosed with PHSCD and reported their clinical, refractive, and topographic/tomographic findings. RESULTS: Most of the eyes were white and quiet. Minimal variable injection was present in a few eyes usually in the presence of pseudopterygium. Typical corneal involvement consists of peripheral circumferential-elevated whitish subepithelial opacities with fine superficial vessels along the limbus and linear deposits of iron in the epithelium along the central edge of the opacification. The typical topographic/tomographic findings consist of flattening directly over the corneal opacification with central flattening aligning with the axis of the opacification. In all subjects, the mean refractive astigmatism was significantly less than the mean topographic/tomographic Sim K astigmatism. Thirty-five eyes underwent surgical excision. The surgical eyes demonstrated significantly less astigmatism and better best-spectacle corrected visual acuity than pre-op. Moreover, all the eyes that underwent surgery for discomfort experienced significant improvement in their symptoms. Histopathology of the keratectomy specimens demonstrated paucicellular subepithelial fibrosis with overlying epithelium that was variable in caliber. CONCLUSIONS: PHSCD is distinct from SND, primarily occurring in middle-aged women, bilateral and fairly symmetric with larger more peripheral opacities than SND, and absence of inflammatory signs and symptoms.

Endophthalmitis Rates and Clinical Outcomes Following Penetrating and Endothelial Keratoplasty.

PURPOSE: To evaluate endophthalmitis rates after penetrating keratoplasty (PK) and endothelial keratoplasty (EK) and to compare clinical outcomes. DESIGN: Retrospective cohort study. METHODS: The medical and billing records of several large academic private practices in Philadelphia, PA were electronically queried for all surgical visits during which a PK or EK was performed between April 1, 2012 and August 31, 2018. Demographic information and transplant characteristics were recorded for each patient and office visit. An additional query was performed to identify all cases of endophthalmitis based on diagnosis and procedure billing codes. Charts of patients with endophthalmitis were individually reviewed, and information was collected on triggering factors, clinical evaluation at presentation, management, culture data, visual outcomes, and graft survival rates. The main outcome measure was incidence of presumed infectious endophthalmitis following PK or EK. RESULTS: During the study period, 1676 PKs and 2292 EKs for 3069 patients were performed. The mean age of patients in this transplant cohort was 66.4 (± 17.5) years and 54.6% of patients were women. Sixteen cases of endophthalmitis occurred during the study period; 12 cases of endophthalmitis occurred after PK and 4 cases occurred after EK. The rate of endophthalmitis after EK (4 of 2292; 0.2%) was significantly lower than that after PK (12 of 1676; 0.7%) (P = .01). In addition, the odds of developing endophthalmitis after PK or EK performed in conjunction with anterior vitrectomy were significantly higher than after either PK or EK alone (odds ratio 8.66; 95% confidence interval 2.98-25.18; P < .001). Visual acuity outcomes were poorer after PK-related endophthalmitis than EK-associated cases (P = .01). The rate of graft failure at final follow-up was significantly higher in post-PK endophthalmitis (P = .02). CONCLUSIONS: In this large cohort of patients undergoing either PK or EK, rates of endophthalmitis were low for both procedures and significantly lower for EK compared with PK. Eyes with endophthalmitis after PK had poorer visual acuity outcomes and graft prognosis compared with those with endophthalmitis after EK.

Effect of Graft Attachment Status and Intraocular Pressure on Descemet Stripping Automated Endothelial Keratoplasty Outcomes in the Cornea Preservation Time Study.

PURPOSE: To examine the association of donor, recipient, and operative factors on graft dislocation after Descemet stripping automated endothelial keratoplasty (DSAEK) in the Cornea Preservation Time Study (CPTS) as well as the effects of graft dislocation and elevated IOP on graft success and endothelial cell density (ECD) 3 years postoperatively. DESIGN: Cohort study within a multi-center, double-masked, randomized clinical trial. METHODS: 1090 individuals (1330 study eyes), median age 70 years, undergoing DSAEK for Fuchs endothelial corneal dystrophy (94% of eyes) or pseudophakic or aphakic corneal edema (6% of eyes). Recipient eyes receiving donor corneal tissue randomized by preservation time (PT) of 0-7 days (N = 675) or 8-14 days (N = 655) were monitored for early or late graft failure through 3 years. Donor, recipient, operative, and postoperative parameters were recorded including graft dislocation (GD), partial detachment, and pre- and post-operative IOP. Pre- and postoperative central donor ECD were determined by a central image analysis reading center. Proportional hazards, mixed effects, and logistic regression models estimated risk ratios and (99% confidence intervals). RESULTS: Three independent predictive factors for GD were identified: a history of donor diabetes (odds ratio [OR]: 2.29 [1.30, 4.02]), increased pre-lamellar dissection central corneal thickness (OR: 1.13 [1.01, 1.27] per 25µ increase), and operative complications (OR: 2.97 [1.24, 7.11]). Among 104 (8%) eyes with GD, 30 (28.9%) developed primary donor or early failure and 5 (4.8%) developed late failure vs. 15 (1.2%; P < .001) and 29 (2.4%; P = .04), respectively, of 1226 eyes without GD. 24 (2%) of 1330 study eyes had early acutely elevated postoperative IOP that was associated with a higher risk of graft failure through 3 years (hazard ratio: 3.42 [1.01, 11.53]), but not with a lower mean 3-year ECD (mean difference 61 (-479, 601) cells/mm2, P = .77). History of elevated postoperative IOP beyond 1 month was not significantly associated with 3-year graft success or ECD. CONCLUSIONS: Donor diabetes, increased donor corneal thickness, and intraoperative complications were associated with an increased risk of GD. Early acutely elevated postoperative IOP and GD significantly increased the risk for graft failure following DSAEK.

Influence of Early Descemet Stripping Endothelial Keratoplasty on Visual Outcomes in Pseudophakic Corneal Edema.

PURPOSE: Longstanding corneal edema can lead to anterior stromal scarring that may limit visual acuity following Descemet stripping endothelial keratoplasty (DSEK). The ideal time to perform DSEK to prevent permanent changes is unclear. Our aim is to determine whether earlier DSEK is associated with improved visual outcomes. DESIGN: Cohort study. METHODS: Setting: Institutional. STUDY POPULATION: Total of 120 eyes of patients who underwent DSEK for corneal edema following cataract surgery (CE); 87% of eyes had a diagnosis of Fuchs dystrophy. INTERVENTION: Post-DSEK visual acuity was compared in patients who underwent DSEK ≤6 months vs >6 months after CE. Linear and logistic regression were performed to assess the relationships between DSEK timing and best spectacle-corrected visual acuity (BSCVA) while accounting for baseline preoperative patient characteristics. MAIN OUTCOME MEASURES: Postoperative best-corrected visual acuity 6 months after DSEK (POM6 BSCVA). RESULTS: Median CE-to-DSEK time was 8.62 (interquartile range [IQR] 12.28) months (n = 120). Overall median preoperative VA and POM6 BSCVA were 0.54 (IQR 0.68) and 0.24 (IQR 0.16), respectively. Median POM6 BSCVA was better in patients with CE-to-DSEK time ≤6 months (median 0.18, IQR 0.19) vs >6 months (median 0.30, IQR 0.21) (P = .014). A significant relationship was found between CE-to-DSEK time and POM6 BSCVA (coefficient = 0.002, P = .033), accounting for preoperative vision and pachymetry. Patients who underwent DSEK ≤6 months after CE were more likely to achieve POM6 BSCVA better than 20/40 (odds ratio = 3.73 P = .035). CONCLUSION: Performing earlier DSEK for pseudophakic corneal edema appears to be associated with improved vision. Further prospective study is warranted to determine the optimal time to perform DSEK in patients with pseudophakic corneal edema.

Sequential versus concomitant surgery of glaucoma drainage implant and Boston keratoprosthesis type 1.

PURPOSE: To compare sequential versus concomitant surgery of glaucoma drainage implant (GDI) and Boston keratoprosthesis type 1 (KPro). METHODS: Patients who received GDI and KPro in the same eye were divided into 2 groups: GDI placement prior to KPro surgery (sequential group) or GDI placement concomitant with KPro surgery (concomitant group). Main outcome measures were GDI failure, defined as intraocular pressure (IOP) >21 mm Hg, less than a 20% IOP reduction from baseline, or IOP <5 mm Hg on 2 consecutive follow-up visits, any reoperation for glaucoma, or loss of light perception; best-corrected visual acuity (BCVA); and surgical complications. RESULTS: Thirty-five eyes were included in the study: 17 in the sequential group and 18 in the concomitant group. The cumulative incidence of failure after 5 years of follow-up was 23.5% in the sequential group and 27.8% in the concomitant group (p = 0.250). Mean BCVA was significantly better in the concomitant group after 6 months, 1 year, 2 years, and at the last follow-up (p<0.05). Both groups had similar rates of complications (p = 1.000). The most frequent complication was GDI erosion, which occurred in 23.5% (n = 4/17) in the sequential group and in 27.8% (n = 5/18) in the concomitant group (p = 1.000). CONCLUSIONS: Glaucoma drainage implant placement at the time of KPro surgery had similar cumulative incidence of failure, but significantly favorable visual outcomes, compared to sequential surgeries. The most frequent complication was GDI erosion, occurring in approximately one fourth of the patients.

Scleral fixation of intraocular lenses using Gore-Tex suture: clinical outcomes and safety profile.

BACKGROUND/AIMS: To report the short-term safety profile and clinical outcomes of scleral fixation of intraocular lenses (IOLs) using Gore-Tex suture. METHODS: Retrospective, interventional case series. 85 eyes of 84 patients undergoing ab externo scleral fixation of a Bausch and Lomb Akreos AO60 or Alcon CZ70BD IOL using Gore-Tex suture. Primary outcome measures were change in visual acuity and occurrence of intraoperative and postoperative complications with minimum follow-up of 90 days. RESULTS: 85 eyes of 84 patients were identified. Mean logarithm of the minimum angle of resolution visual acuity improved from 1.43±0.72 (20/538 Snellen equivalent) preoperatively to 0.64±0.61 (20/87 Snellen equivalent) postoperatively (p<0.001). Mean follow-up was 325 days (median 264 days, range 90-996 days). There were no intraoperative complications noted. Postoperative complications included hypotony in eight patients (9.4%), ocular hypertension in six eyes (7%), vitreous haemorrhage in six eyes (7%), hyphema in two eyes (2%), serous choroidal detachment in two eyes (2%), cystoid macular oedema in two eyes (2%) and corneal oedema in one eye (1%). There were no cases of postoperative endophthalmitis, suture erosion/breakage, retinal detachment, suprachoroidal haemorrhage, uveitis-glaucoma-hyphema syndrome or persistent postoperative inflammation in the follow-up period. CONCLUSIONS: Ab externo scleral fixation of IOLs with Gore-Tex suture was well tolerated in all cases. No suture-related complications were encountered. This procedure led to improvement in visual acuity and was not associated with significant intraoperative or postoperative complications.

Long-Term Results of the Boston Keratoprosthesis for Unilateral Corneal Disease.

PURPOSE: To report the results of unilateral implantation of a Boston keratoprosthesis (BKPro) in patients with good visual acuity in the fellow eye. METHODS: A retrospective analysis of 37 eyes of 37 patients who underwent an optical BKPro and had a preoperative best-corrected visual acuity (BCVA) of 20/40 or better in the fellow eye at Wills Eye Hospital from September 2005 to November 2013 was performed. Patients were excluded if they had less than 1 year of postoperative follow-up. RESULTS: The mean follow-up after BKPro implantation was 31.7 months (range, 12-78 months; SD, 21). Twenty-eight patients underwent a BKPro for failed penetrating keratoplasty, and 9 patients underwent a primary BKPro. The most common complications were elevated intraocular pressure and retroprosthetic membrane formation in 16 eyes (43%) each. The mean final BCVA (1.0 ± 0.8 logMAR; median, 1.0 logMAR) was statistically better than the mean preoperative BCVA (1.8 ± 0.2 logMAR; median, 1.8 logMAR) (P < 0.001). The probability of postoperative BCVA of 20/200 or better was 54.1% with an average 45.1 ± 4.7 (confidence interval: 35.9-54.3) months of follow-up. The probability of postoperative BCVA of 20/40 or better was 37.8% with an average 51.8 ± 4.9 (confidence interval: 42.0-61.5) months of follow-up. CONCLUSIONS: Half of the patients in our study achieved the minimum visual acuity required for binocular functioning, whereas one-third of the patients achieved a BCVA somewhat similar to that of the contralateral eye. The complications were similar to those reported previously with good retention of the device. BKPro implantation is a reasonable option for patients with good vision in the fellow eye.

The effect of donor age on penetrating keratoplasty for endothelial disease: graft survival after 10 years in the Cornea Donor Study.

OBJECTIVE: To determine whether the 10-year success rate of penetrating keratoplasty for corneal endothelial disorders is associated with donor age. DESIGN: Multicenter, prospective, double-masked clinical trial. PARTICIPANTS: A total of 1090 participants undergoing penetrating keratoplasty at 80 sites for Fuchs' dystrophy (62%), pseudophakic/aphakic corneal edema (34%), or another corneal endothelial disorder (4%) and followed for up to 12 years. METHODS: Forty-three eye banks provided corneas from donors aged 12 to 75 years, using a randomized approach to assign donor corneas to study participants without respect to recipient factors. Surgery and postoperative care were performed according to the surgeons' usual routines. MAIN OUTCOME MEASURES: Graft failure defined as a regraft or, in the absence of a regraft, a cloudy cornea that was sufficiently opaque to compromise vision for 3 consecutive months. RESULTS: In the primary analysis, the 10-year success rate was 77% for 707 corneas from donors aged 12 to 65 years compared with 71% for 383 donors aged 66 to 75 years (difference, +6%; 95% confidence interval, -1 to +12; P = 0.11). When analyzed as a continuous variable, higher donor age was associated with lower graft success beyond the first 5 years (P<0.001). Exploring this association further, we observed that the 10-year success rate was relatively constant for donors aged 34 to 71 years (75%). The success rate was higher for 80 donors aged 12 to 33 years (96%) and lower for 130 donors aged 72 to 75 years (62%). The relative decrease in the success rate with donor ages 72 to 75 years was not observed until after year 6. CONCLUSIONS: Although the primary analysis did not show a significant difference in 10-year success rates comparing donor ages 12 to 65 years and 66 to 75 years, there was evidence of a donor age effect at the extremes of the age range. Because we observed a fairly constant 10-year success rate for donors aged 34 to 71 years, which account for approximately 75% of corneas in the United States available for transplant, the Cornea Donor Study results indicate that donor age is not an important factor in most penetrating keratoplasties for endothelial disease.

Classification of posterior polymorphous corneal dystrophy as a corneal ectatic disorder following confirmation of associated significant corneal steepening.

IMPORTANCE: The identification of steep corneal curvatures in a significant percentage of patients with posterior polymorphous corneal dystrophy (PPCD) confirms this previously reported association and suggests a role for the ZEB1 protein in keratocyte function. OBJECTIVE: To determine whether PPCD is characterized by significant corneal steepening. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional study at university-based and private ophthalmology practices of 38 individuals (27 affected and 11 unaffected) from 23 families with PPCD. EXPOSURE: Slitlamp examination and corneal topographic imaging were performed for individuals with PPCD and unaffected family members. Saliva or blood samples were obtained from each individual for DNA isolation and ZEB1 sequencing. Corneal ZEB1 expression was measured using immunohistochemistry. MAIN OUTCOMES AND MEASURES: Percentage of individuals affected with PPCD and controls with an average keratometric value greater than 48.0 diopters (D) in each eye; the mean keratometric value averaged for both eyes of individuals with PPCD and controls; and the correlation of ZEB1 mutation with keratometric value. RESULTS: ZEB1 coding region mutations were identified in 7 of the 27 affected individuals. Ten of the 38 individuals (26.3%) had average keratometric values greater than 48.0 D OU: 10 of 27 individuals with PPCD (37.0%; 6 of 7 individuals with ZEB1 mutations [85.7%] and 4 of 20 individuals without ZEB1 mutations [20.0%]) and 0 of 11 unaffected individuals (P = .04 for unaffected vs affected individuals; P = .004 for individuals with PPCD with vs without ZEB1 mutation). The mean keratometric value of each eye of affected individuals (48.2 D) was significantly greater than that of each eye of unaffected family members (44.1 D) (P = .03). Affected individuals with ZEB1 mutations demonstrated a mean keratometric value of 53.3 D, which was significantly greater than that of affected individuals without ZEB1 mutations (46.5 D; P = .004). Fluorescence immunohistochemistry demonstrated ZEB1 expression in keratocyte nuclei. CONCLUSIONS AND RELEVANCE: Abnormally steep corneal curvatures are identified in 37% of all individuals with PPCD and 86% of affected individuals with PPCD secondary to ZEB1 mutations. ZEB1 is present in keratocyte nuclei, suggesting a role for ZEB1 in keratocyte function. Therefore, ZEB1 may play a role in both corneal stromal and endothelial development and function, and PPCD should be considered both an endothelial dystrophy and an ectatic disorder.

Sutureless amniotic membrane ProKera for ocular surface disorders: short-term results.

OBJECTIVE: To evaluate the indications and outcomes of sutureless amniotic membrane transplant (AMT; ProKera) in the management of ocular surface disorders. METHODS: Chart review of patients who had ProKera (Bio-Tissue, Inc.) implantation for ocular surface disorders between June 2008 and May 2012 at 3 ophthalmology practices in Philadelphia, PA. The parameters evaluated included age, sex, indication for AMT, any other combined procedure, duration of retention of amniotic membrane, the effect of amniotic membrane on ocular surface healing, follow-up time, and complications. RESULTS: There were 35 eyes of 33 patients with a mean age of 68.2±19.5 years (range: 17-99 years). There were 25 male patients, and median follow-up was 110 days (mean: 164.6 days; range: 30-960 days). The indication for insertion of ProKera was nonhealing corneal ulcers of infective origin (group 1) in 9 eyes (25.7%), neurotrophic keratopathy (group 2) in 11 eyes (31.4%), chemical injury (group 3) in 5 eyes (14.3%), and other indications (group 4) in 10 eyes (28.6%). Complete or partial success was seen in a total of 44%, 64%, 80%, and 70% eyes in groups 1 to 4, respectively. Discomfort with the device was seen in 6 (17.1%) of 35 eyes, and recurrence of primary pathologic condition occurred in 5 (14.3%) of 35 eyes. CONCLUSION: ProKera treatment is easy to use and reasonably well tolerated, with moderate success in corneal ulcers and encouraging results in acute moderate chemical injury. Recurrence of primary pathologic condition is seen particularly associated with neurotrophic keratitis and dry eye syndrome.

Posterior polymorphous dystrophy associated with nonkeratoconic steep corneal curvatures.

PURPOSE: To report a case series of eyes with posterior polymorphous corneal dystrophy and steep nonkeratoconic corneas. METHODS: Retrospective, descriptive, nonrandomized case series. RESULTS: Thirty-five eyes of 18 patients (14 cases from 6 families and 4 isolated cases) with diffuse posterior polymorphous corneal dystrophy had mean topographic simulated keratometry readings of 52.21 diopters (D), with a range of 46.47 D to 59.86 D and an SD of 3.69 D, with no slit-lamp or topographic findings suggestive of keratoconus. CONCLUSIONS: The patients in this series demonstrate diffuse posterior polymorphous corneal dystrophy and nonkeratoconic steep corneas.

Post-traumatic fungal keratitis caused by Carpoligna sp.

PURPOSE: To report the first case of fungal keratitis caused by presumed Carpoligna species. METHODS: A 37-year-old gardener sustained a full-thickness, stellate corneal laceration while cutting wood outdoors with a circular saw. Two months after surgical repair, he developed a severe infectious keratitis with descemetocoele at the apex of the original stellate laceration. RESULTS: Culture results confirmed fungal elements without evidence of bacteria. Oral and topical voriconazole were initiated. Due to compliance and cost issues, voriconazole was replaced with natamycin 5% prior to discharge from hospital. The patient improved and healed without perforation. The patient was left with a central stromal scar. DNA extraction from the fungal colony allowed PCR amplification of the 28s ribosomal RNA region of the fungus that led to the diagnosis of Carpoligna pleurothecii. Corticosteroids were never used during the patient's treatment. CONCLUSION: This is the first reported case of infectious keratitis caused by presumed Carpoligna species. The treatment for Carpoligna pleurothecii keratitis includes voriconazole, natamycin, and possibly amphotericin B.

Indications for penetrating keratoplasty and associated procedures, 2001-2005.

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.

Histopathology of posterior lamellar endothelial keratoplasty graft failure.

PURPOSE: To describe the histopathologic findings and relevant clinical details of 3 patients undergoing penetrating keratoplasty (PK) after failure of posterior lamellar endothelial keratoplasty (EK). METHODS: Retrospective clinicopathologic case series. Patients 1 and 2 underwent EK for pseudophakic bullous keratopathy. Patient 3 underwent EK for persistent corneal edema secondary to a Descemet membrane (DM) detachment after cataract extraction. Patient 1 had persistent diffuse corneal edema and broad, long-standing iridocorneal adhesions that precluded repeat EK. Patient 2 had high intraocular pressure and severe anterior chamber inflammation 1 day postoperatively with subsequent noncorneal clearing and elected PK over repeat EK. Progressive corneal edema with resultant poor visual acuity after EK was the reason for PK in patient 3. RESULTS: Histopathologic examination disclosed thickened, edematous corneas with attenuated endothelium consistent with graft failure caused by endothelial decompensation in all 3 cases. Although various degrees of posterior lamellar graft detachment were observed in each instance, significant parts of each graft remained adherent to the host stroma or to segments of residual host DM. The wounds in the adherent areas, although discernible, were relatively inconspicuous, resembling those seen at the flap-stromal interface after laser in situ keratomileusis. The donor graft endothelium was atrophic in all cases, and a delicate retrocorneal fibrous membrane was present in 2 cases. Most of the graft in cases 1 and 2 remained adherent, with small areas of peripheral detachment. In contrast, the graft in case 3 adhered peripherally but had separated from the stroma centrally, forming a thin cleft. CONCLUSIONS: Histopathology suggests endothelial decompensation, incomplete graft adherence, and the formation of retrocorneal fibrous membranes as possible etiologies for EK failure. The adherence of endothelial grafts to residual host DM suggests that it may not be necessary to remove optically clear DM before endothelial graft placement. The inconspicuous nature of the EK interface suggests that it may not play a large role in image degradation, although more study is needed.

Trends in penetrating keratoplasty in the United States 1980-2005.

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.

Successful management of aniridic ocular surface disease with long-term bandage contact lens wear.

PURPOSE: To present an aniridic patient with failed penetrating keratoplasties OU (PK) who underwent successful repeat PK OD, which has remained clear for 4 years with continuous bandage lens (BCL) wear. METHODS: A 73-year-old aniridic woman who had a failed PK complicated by ocular surface disease refused limbal stem cell transplantation and underwent repeat PK in her right eye. The immediate postoperative course was uneventful except for mild irregularity of the graft epithelium. Two months postoperatively, she presented with an epithelial defect along the inferotemporal graft margin adjacent to an exposed, loose interrupted suture. The suture was removed, and although the initial epithelial defect healed, she suffered recurrent episodes of epithelial breakdown and generalized whorl epitheliopathy. A BCL was inserted and rendered prompt healing of the graft epithelium, which has remained smooth and intact for 4 years. RESULTS: The graft remains thin and clear with a smooth and intact epithelial surface beneath the BCL and no signs of limbal stem-cell deficiency. CONCLUSION: Long-term BCL wear provided good corneal transplant surface protection in an aniridic patient with recurrent epithelial breakdown, thereby sparing the need for limbal stem cell transplantation and the use of potentially toxic systemic immunosuppressive therapy. Meticulous follow-up is required to monitor contact lens loss and epithelial breakdown as well as signs of secondary infectious keratitis.

Ferrara intracorneal ring implantation and cataract surgery for the correction of pellucid marginal corneal degeneration.

We report a case of Ferrara intracorneal ring (Mediphacos) implantation and cataract surgery for the correction of pellucid marginal corneal degeneration. Preoperatively, the patient's uncorrected visual acuity (UCVA) was 0.05 in the right eye and 0.10 in the left eye. The best spectacle-corrected visual acuity (BSCVA) was 0.50 with -2.00 -11.25 x 80 in the right eye and 0.60 with -2.00 -5.50 x 95 in the left eye. One month postoperatively, the UCVA was 0.50 in the right eye and 0.30 in the left eye. The BSCVA was 0.80 with -1.00 in the right eye and 0.60 with -0.75 -1.25 x 160 in the left eye. Ferrara intrastromal rings and cataract surgery resulted in a more regular corneal shape with a reduction in astigmatism for good visual recovery.

Conjunctival metastasis as initial sign of disseminated cutaneous melanoma.

PURPOSE: To describe a patient with conjunctival metastasis as the initial manifestation of metastasis from a cutaneous melanoma. DESIGN: Single interventional case report. METHODS: A 48-year-old woman with a history of cutaneous axillary melanoma developed a rapidly growing conjunctival mass. Subsequent systemic evaluation disclosed asymptomatic liver metastasis. The conjunctival lesion was resected. RESULTS: Histopathologic evaluation of the conjunctival tumor disclosed an epithelioid cell melanoma located in the conjunctival stroma, without appreciable junctional activity, compatible with metastatic melanoma. CONCLUSIONS: Conjunctival metastasis from cutaneous melanoma can rarely be the initial manifestation of disseminated melanoma.