Deep anterior lamellar keratoplasty for acanthamoeba keratitis complicating the use of Boston scleral lens.

BACKGROUND: This is the first reported case of Acanthamoeba keratitis (AK) in a Boston scleral lens user. Consequently, the risk factors and treatment for AK need to be addressed in this unique case. METHODS: We conducted a retrospective case study of a 45-year-old man using Boston scleral lens diagnosed with AK. Risk factors for infection and management of the condition were assessed. RESULTS: This 45-year old Boston scleral lens user's risk factors for developing AK included dry eye syndrome, autologous serum tear use, potential tap water exposure, and long-term systemic corticosteroid use. His infection was refractory to medical management and required deep anterior lamellar keratoplasty for curative treatment. CONCLUSION: Ophthalmologists should have a higher level of suspicion for AK in all scleral lens users and consider the use of deep anterior lamellar keratoplasty for refractory cases.

Comparison of outcomes of penetrating keratoplasty versus Descemet's stripping automated endothelial keratoplasty for penetrating keratoplasty graft failure due to corneal edema.

To evaluate the outcomes of repeat corneal transplantation, either penetrating keratoplasty (PKP) or Descemet's stripping automated endothelial keratoplasty (DSAEK), for penetrating keratoplasty grafts which failed due to corneal edema. The charts of 24 eyes with failed PKP grafts, due to corneal edema, which underwent a repeat corneal transplant (PKP in 17 eyes [Group 1] and DSAEK in seven eyes [Group 2]) between 2003 and 2007 were retrospectively reviewed. There was no statistically significant difference in the median postoperative visual acuity between the two groups at 1, 2, or 3 years. In Group 1, two (18%) eyes had a final visual acuity ≥ 20/40, in contrast to four (80%) eyes in Group 2, which was statistically significant (P = 0.038). Seven (41%) of the Group 1 eyes developed postoperative complications compared to only one (14%) eye in Group 2. Eleven (65%) of the Group 1 eyes and five (71%) of Group 2 eyes had clear grafts on the last examination. There was no statistically significant difference in the graft survival rate for Group 1 versus Group 2 at 3 years (57.9% vs 68.6%, P = 0.507). There was a trend towards better postoperative visual acuity, a lower postoperative complication rate, and a higher graft survival rate in eyes that underwent DSAEK rather than repeat PKP for graft failure secondary to corneal edema. Given this small, retrospective study, future studies comparing repeat PKP with DSAEK are warranted to determine which procedure allows for improved outcomes.

Glaucoma therapy escalation in eyes with pseudophakic corneal edema after penetrating keratoplasty and Descemet's stripping automated endothelial keratoplasty.

The purpose of this study was to determine and compare the prevalence of glaucoma therapy escalation (GTE) after penetrating keratoplasty (PKP) and Descemet's stripping automated endothelial keratoplasty (DSAEK) in eyes with a surgical indication of pseudophakic corneal edema. A retrospective review was conducted of the medical records of all patients who underwent PKP or DSAEK to treat pseudophakic corneal edema at a tertiary eye care center from January 1 2003 to December 31, 2006. Eyes that were treated with PKP from January 1, 2003 to December 31, 2004 and with DSAEK from January 1, 2005 to December 31, 2006 were included in the statistical analysis. Inclusion criteria included satisfactory preoperative control of intraocular pressure (IOP) and follow-up of at least 12 months. The main outcome measure was GTE, which was defined as a sustained requirement for escalation of topical medical therapy or the need to provide surgical intervention to maintain a satisfactory postoperative IOP. Among 54 eyes that met the inclusion criteria, GTE occurred in 7 (35.0%) of 20 eyes after PKP and in 14 (41.2%) of 34 eyes after DSAEK (P = 0.78) during a mean follow-up period of 27.6 and 28.6 months, respectively. Surgical escalation occurred in 2 (10.0%) eyes after PKP and 2 (5.9%) eyes after DSAEK (P = 0.62), and was associated with late-onset endothelial graft failure in all four eyes. Glaucoma therapy escalation is relatively common and occurs with comparable frequency in eyes with pseudophakic corneal edema after PKP and DSAEK.

Correlation of Measures From the OCULUS Keratograph and Clinical Assessments of Dry Eye Disease in the Dry Eye Assessment and Management Study.

PURPOSE: The purpose of this study was to compare objective, noninvasive assessments of tear function using the OCULUS Keratograph with the corresponding clinical assessments [tear break-up time (TBUT), Schirmer test, and bulbar erythema] among patients with moderate-to-severe dry eye disease. METHODS: Participants in the Dry Eye Assessment and Management study at centers having an OCULUS Keratograph were assessed using standardized procedures. Associations between the assessments from the Keratograph [noninvasive keratograph break-up time (NIKBUT), tear meniscus height (TMH), and bulbar redness (BR)] and clinical examination (TBUT, Schirmer test, and bulbar erythema) and between these test results and Ocular Surface Disease Index (OSDI) scores were summarized with Spearman correlation coefficients (r s ); 95% confidence intervals (95% CI) accounted for intereye correlation. RESULTS: Among 288 patients (576 eyes), the mean (standard deviation) age was 56.6 (13.8) years, 78.1% were female, and the mean baseline OSDI score was 44.3 (14.0). The mean was 2.9 (1.5) seconds for TBUT and 8.2 (5.7) seconds for NIKBUT (their correlation r s = 0.18, 95% CI = 0.09-0.28). The mean was 10.6 (7.6) mm for the Schirmer test and 0.3 (0.2) mm for TMH (r s = 0.15, 95% CI = 0.04-0.25). The median clinical grade redness was mild, and the mean BR score was 1.1 (0.5) (r s = 0.25, 95% CI = 0.15-0.35). Correlation between results of each of the 6 tests and OSDI scores was low (r s from -0.07 to 0.05). CONCLUSIONS: In the Dry Eye Assessment and Management study, NIKBUT, TMH, and BR were weakly correlated with their clinical counterparts. No measurements were correlated with the OSDI score.

Initial resident refractive surgical experience: outcomes of PRK and LASIK for myopia.

PURPOSE: To evaluate and compare the outcome of initial resident surgical experience with photorefractive keratectomy (PRK) and LASIK. METHODS: Retrospective review of all cases performed with the VISX Star S4 platform (Abbott Medical Optics) between July 1, 2003 and June 30, 2007. Inclusion criteria were spherical equivalent of -0.50 to -10.00 diopters (D), refractive astigmatic error of ≤3.00 D, intention to provide full distance correction, and minimum 3-month postoperative follow-up after initial ablation or retreatment (if performed). RESULTS: A total of 153 cases performed by 20 different residents met the inclusion criteria; 38 eyes underwent PRK and 115 eyes had LASIK. After initial treatment, mean Snellen uncorrected distance visual acuity (UDVA) after PRK was 20/17.3 and after LASIK was 20/19.5. Photorefractive keratectomy was associated with a significantly better approximation between preoperative corrected distance visual acuity (CDVA) and postoperative UDVA (ΔlogMAR 0.009 vs 0.091; P=.004) and a greater percentage of eyes that achieved UDVA of 20/20 or better (94.7% vs 78.3%; P=.02) or 20/30 or better (100% vs 87.8%; P=.02). There was a higher prevalence of retreatment in eyes that underwent LASIK (7.0% vs 0%; P=.20). One (0.9%) eye lost 2 lines of CDVA after LASIK. CONCLUSIONS: Supervised refractive surgery residents can achieve excellent visual outcomes in patients operated during their initial refractive experience. Photorefractive keratectomy was associated with better visual outcome than LASIK.

Unilateral retinopathy post perilesional interferon α2b injections for ocular surface squamous cell carcinoma.

PURPOSE: To describe the clinical course of a patient presenting with unilateral retinopathy after perilesional interferon alpha injections for treatment of ocular surface squamous cell carcinoma. OBSERVATIONS: A patient, who was being treated with interferon alpha for ocular squamous cell carcinoma, presented with new onset decreased vision in her left eye. Upon examination, she was found to have cotton wool spots and retinal hemorrhages in the affected eye. CONCLUSIONS AND IMPORTANCE: Retinopathy is a well-documented side effect of systemic usage of interferon alpha. However, retinopathy has not been well discussed in the scenario of perilesional injections of interferon. It is important for clinicians to monitor for such pathology when using interferon alpha not only systemically, but also locally.

Penetrating keratoplasty versus deep anterior lamellar keratoplasty for the treatment of keratoconus.

PURPOSE: To compare the outcome of penetrating keratoplasty (PKP) and deep anterior lamellar keratoplasty (DALK) in the surgical management of keratoconus (KC). PATIENT AND METHODS: A retrospective review was conducted of the medical records of all patients treated with PKP or DALK for KC at University of Iowa Hospitals and Clinics from January 1, 2000, to December 31, 2006. The main outcome measures were visual outcome, graft survival, and complications. Cases with a minimum follow-up of 6 months were included in the statistical analysis. RESULTS: Of 41 eyes that met the inclusion criteria, 30 eyes were treated with PKP and 11 eyes were treated with DALK. The mean follow-up was almost identical for eyes treated with PKP or DALK (21.9 vs. 22.5 months, respectively). At the most recent examination, the mean best spectacle-corrected visual acuity (BSCVA) was 20/28 for the PKP group and 20/29 for the DALK group (P = 0.77). The percentage of eyes that achieved BSCVA of 20/25 or better was higher in the PKP group than in the DALK group (77.3 vs. 45.5%, respectively), but this difference was not statistically significant (P = 0.72). Endothelial rejection occurred in 4 (13.3%) eyes after PKP. Visually significant interface haze occurred in the early postoperative course in 2 (18.2%) eyes after DALK. No cases of late-onset endothelial failure were found in either group. CONCLUSION: Treatment of KC with PKP or DALK is associated with similar visual outcomes, graft survival, and prevalence of sight-threatening complications.

Keratoplasty for treatment of Acanthamoeba keratitis.

PURPOSE: To evaluate and compare the outcomes of therapeutic keratoplasty (TKP) and optical keratoplasty (OKP) in the management of medically unresponsive Acanthamoeba keratitis and post-keratitis scarring, respectively. DESIGN: Retrospective, nonrandomized, comparative, interventional case series. PARTICIPANTS: Thirty patients with Acanthamoeba keratitis treated at a single center. METHODS: Retrospective review of all cases of penetrating keratoplasty (PKP) or lamellar keratoplasty (LKP) performed for Acanthamoeba keratitis at a single center between January 1, 1980, and December 31, 2007. Inclusion criteria included histopathologic confirmation of Acanthamoeba organisms in the surgical specimen and at least 6 months of postoperative follow-up. MAIN OUTCOME MEASURES: Postoperative complications, microbiological cure, graft survival, and visual acuity. RESULTS: Thirty-one eyes of 30 patients met the inclusion criteria. This included 22 eyes (22 patients) that were initially treated with TKP (20 PKP/2 LKP) and 9 eyes (8 patients) treated with OKP (8 OKP/1 LKP). Of the 22 eyes treated with TKP, multiple keratoplasties (range, 2-6) were performed in 12 eyes (55%), whereas repeat keratoplasty was performed in only 1 eye (11%) treated with OKP (P = 0.004). Recurrent Acanthamoeba keratitis, glaucoma, early and late persistent epithelial defects, and endophthalmitis were more likely to occur after TKP than after OKP. A microbiological cure was achieved in all surgical cases. Among eyes treated with TKP, this required 1 keratoplasty in 14 eyes, 2 keratoplasties in 6 eyes, and 3 keratoplasties in 2 eyes. After the initial keratoplasty, Kaplan-Meier survivals after TKP were 45.5%, 45.5%, and 37.5% at 1 year, 5 years, and 10 years, respectively, compared with 100%, 100%, and 66.7%, respectively, after OKP (P = 0.004). The median visual acuity was 20/40 after TKP and 20/25 after OKP. Eyes treated with TKP were less likely to obtain visual acuity of 20/40 or better and more likely to have vision of 20/200 or worse. CONCLUSIONS: Therapeutic keratoplasty can successfully treat medically unresponsive cases of Acanthamoeba keratitis, although multiple grafts may be required and the visual prognosis is guarded. Optical keratoplasty performed after resolution of active keratitis is associated with an excellent prognosis for both graft survival and visual outcome. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Comparison of the femtosecond laser (IntraLase) versus manual microkeratome (Moria ALTK) in dissection of the donor in endothelial keratoplasty: initial study in eye bank eyes.

PURPOSE: To determine the safety and efficacy of a femtosecond laser (IntraLase) and manual microkeratome (Moria ALTK) in creating precut endothelial keratoplasty donor tissue. METHODS: Sixteen corneoscleral buttons from 8 donors were evaluated within 2 days of the death of the donor. The mean donor age was 72 years, and mean death-to-preservation time was 11 hours. Eight eyes underwent deep lamellar keratectomy by using the femtosecond laser (IntraLase: firing rate, 30 kHz; lamellar cut energy, 7.4 microJ; side cut energy, 5.5 microJ; spot size, 10 microm; diameter, 9.0 mm; depth, 400 microm; spiral pattern), whereas the other 8 eyes were cut by using the Moria ALTK microkeratome (350-microm head). Ultrasonic pachymetry and endothelial cell density (ECD) were performed before and after keratectomy. The residual stromal bed was examined with electron microscopy to determine the smoothness of the surface. Cell viability was assessed by using a transferase dUTP nick end labeling (TUNEL) assay. RESULTS: The mean preoperative pachymetry was similar in the microkeratome group and femtosecond laser group (P = 0.239). The microkeratome group obtained a consistently deeper keratectomy of 446 +/- 25 versus 400 +/- 41 microm in the laser group (P = 0.023). Similarly, the residual stromal bed was thinner in the microkeratome group (115 +/- 28.5 vs. 177 +/- 42 microm; P = 0.005). There was no statistically significant difference in the ECD between the 2 groups preoperatively or at 48 hours after keratectomy. Compared with the preoperative state, there was a 1% and 4% reduction of ECD in the microkeratome and femtosecond laser groups, respectively. Scanning electron microscopy of the stromal surface consistently showed a smoother contour in the manual microkeratome group. TUNEL assays indicate no significant endothelial cell loss in either the microkeratome group or the femtosecond laser group. CONCLUSIONS: The femtosecond laser (30 kHz) and the manual microkeratome are equally effective in creating precut endothelial keratoplasty donor tissue, with no detrimental effect on endothelial cell density. The microkeratome creates a smoother stromal surface and thinner endothelial discs. The femtosecond laser lamellar dissection depth is less deep, and the stromal surface is less smooth. This particular feature of femtosecond laser keratectomy may improve disc adherence, which continues to be a problem in endothelial keratoplasty. A prospective, randomized study is needed to evaluate postoperative vision and disc adherence by using both technologies in endothelial keratoplasty.

Bacterial keratitis after penetrating keratoplasty: incidence, microbiological profile, graft survival, and visual outcome.

PURPOSE: To determine the incidence, microbiological profile, graft survival, and factors influencing graft survival after the development of bacterial keratitis after penetrating keratoplasty (PK). DESIGN: Retrospective case series. PARTICIPANTS: One hundred two patients (102 eyes) treated at a single center during a 5-year period. METHODS: Retrospective review of the medical records of every patient treated for culture-positive keratitis between January 1, 1998 and December 31, 2002 who previously had undergone penetrating keratoplasty at the King Khaled Eye Specialist Hospital. MAIN OUTCOME MEASURES: Graft survival and visual outcome. RESULTS: There were 2103 PKs performed and 102 (4.9%) cases of culture-positive keratitis during the study period. There were 168 bacterial isolates, of which 140 (83.3%) were gram positive, 28 (16.7%) were gram negative, and 1 (0.6%) was acid fast. Only 38 (37.3%) grafts remained clear after a mean follow-up of 985 days (range, 82-2284). The best graft survival was in eyes with PK for keratoconus (83.7%), whereas the poorest grat survival was for previously failed grafts (5.6%). By Kaplan-Meier analysis, there was an immediate steep decline in graft survival to 54.9%, followed by a slow decline to 47.2% by 1 year and 35.8% after 4 years. Factors associated with an increased risk of graft failure were the surgical indication for PK (P<0.001), increasing patient age (P = 0.004), smaller donor (P = 0.001) and recipient (P = 0.0003) graft size, history of previous microbial keratitis (P = 0.02) or endothelial rejection episodes (P = 0.02), and coexisting glaucoma (P = 0.001). The visual outcome was > or =20/40 in only 8 (8.2%) eyes and better than 20/200 in only 21 (21.6%) eyes. CONCLUSION: The development of bacterial keratitis after PK is a serious complication that is associated with a high incidence of graft failure and poor visual outcome.

Corneal transplant survival after onset of severe endothelial rejection.

PURPOSE: To evaluate corneal graft survival after onset of severe endothelial rejection after penetrating keratoplasty (PK). DESIGN: Retrospective case series. PARTICIPANTS: One hundred fifty-six patients (161 PKs) treated at a single center. METHODS: Retrospective review of the medical records of every case of severe endothelial rejection admitted to the King Khaled Eye Specialist Hospital (KKESH) between January 1, 1998 and December 31, 2002. Patients for whom PK had been performed at KKESH between June 1, 1983 and December 31, 2002 and in whom at least 3 months of follow-up was available were included in the statistical analysis. MAIN OUTCOME MEASURE: Graft survival. RESULTS: One hundred fifty-seven PKs (152 patients) met the inclusion criteria and were included in the statistical analysis. Four PKs (4 patients) were excluded from the statistical analysis due to inadequate follow-up. The rejection episode was reversed during the first 3 months in 90 grafts (57.3%). By Kaplan-Meier analysis, graft survivals were 42.6% at 1 year and 36.1% at 3 years. The surgical indication for PK significantly correlated with likelihood of reversibility (P<0.001) and long-term graft survival (P<0.001). Risk factors associated with an increased risk of postrejection graft failure included increasing donor age (odds ratio [OR], 1.14; 95% confidence interval [CI], 1.04-1.24; P = 0.004), increasing patient age (OR, 1.23; 95% CI, 1.11-1.35; P<0.001), and history of rejection episodes (P = 0.002). CONCLUSION: Endothelial rejection is a serious complication of PK, with a high risk of graft failure.

Extended long-term outcomes of penetrating keratoplasty for keratoconus.

OBJECTIVE: To report graft survival results for initial penetrating keratoplasty (PK) performed more than 20 years ago for keratoconus. Secondary outcome measures included recurrent keratoconus, best spectacle-corrected visual acuity (BSCVA), and rates of glaucoma. DESIGN: Retrospective, consecutive, noncomparative case series. PARTICIPANTS: All patients with clinical and histopathological keratoconus who underwent initial PK at the University of Iowa Hospitals and Clinics from 1970 to 1983. Patients with pellucid marginal degeneration were excluded. METHODS: At baseline, age, preoperative BSCVA, keratometric astigmatism, and host/donor graft sizes for each eye were recorded. Visual acuity and intraocular pressure were followed until the eyes reached 1 of 4 end points: graft failure, recurrent keratoconus, loss to follow-up, or death. Kaplan-Meier survival analysis was performed to estimate the long-term probability of graft failure and recurrent keratoconus. RESULTS: Among the 112 eyes of 84 patients who met entry criteria, there was a mean age at transplant of 33.7 years and preoperative BSCVA of 20/193. With a mean follow-up of 13.8 years (range, 0.5-30.4), 7 eyes (6.3%) experienced graft failure. Recurrent keratoconus was confirmed clinically or histologically in 6 eyes (5.4%), with a mean time to recurrence of 17.9 years (range, 11-27). Kaplan-Meier analysis estimated a graft survival rate of 85.4% and a rate of recurrent keratoconus of 11.7% at 25 years after initial transplantation. Six eyes (5.4%) developed open-angle glaucoma, and 2 eyes required trabeculectomy. At the last follow-up visit, 82 eyes (73.2%) had BSCVA of 20/40 or better. CONCLUSION: Penetrating keratoplasty offers good long-term visual rehabilitation for keratoconus. Relative to other indications for PK, there is a low rate of graft failure. Late recurrence of disease occurs with increasing frequency over time. Given the younger age at which keratoconus patients undergo corneal transplantation, these long-term findings should be incorporated into preoperative counseling.

Confocal microscopy of subepithelial infiltrates occurring after epidemic keratoconjunctivitis.

PURPOSE: To describe the confocal microscopic findings in subepithelial infiltrates associated with epidemic keratoconjunctivitis (EKC). METHODS: Observational case report. RESULTS: A 14-year-old Saudi girl with keratoconus developed subepithelial infiltrates (SEIs) after the onset of bilateral EKC. Confocal microscopy of the left cornea 8 weeks after the onset of EKC showed many highly reflective dendritic cells at the level of basal epithelium, epithelial basement membrane zone, and anterior stroma, as well as many highly reflective fusiform and round cells within the anterior stroma, with deceasing density in progressively deeper layers of the stroma. These findings were not present on confocal microscopy that had been performed 2 weeks before the onset of EKC. CONCLUSION: Confocal microscopic examination of SEIs after EKC provides evidence of an inflammatory response localized to the basal epithelium and anterior stroma of the central cornea.

Confocal microscopy of subepithelial infiltrates occurring after epidemic keratoconjunctivitis.

PURPOSE: To describe the confocal microscopic findings in subepithelial infiltrates (SEIs) associated with epidemic keratoconjunctivitis (EKC). METHODS: Observational case report. RESULTS: A 14-year-old Saudi girl with keratoconus developed SEIs after the onset of bilateral EKC. Confocal microscopy of the left cornea 8 weeks after the onset of EKC showed many highly reflective dendritic cells at the level of basal epithelium, epithelial basement membrane zone, and anterior stroma, as well as many highly reflective fusiform and round cells within the anterior stroma, with decreasing density in progressively deeper layers of the stroma. These findings were not present on confocal microscopy that had been performed 2 weeks before the onset of EKC. CONCLUSION: Confocal microscopic examination of SEIs after EKC provides evidence of an inflammatory response localized to the basal epithelium and anterior stroma of the central cornea.

Salzmann's nodular corneal degeneration clinical characteristics and surgical outcomes.

PURPOSE: To characterize the clinical characteristics and surgical outcomes for Salzmann's nodular corneal degeneration (SNCD). METHODS: In this retrospective, noncomparative, observational case series, all patients coded with a diagnosis of SNCD between January 1, 1996, and April 30, 2002 were included. Cases whose clinical description did not match the classic description of this disorder were excluded. Clinical characteristics, surgical procedures, and qualitative outcomes were recorded. RESULTS: Among 103 patients diagnosed with SNCD, 93 (152 eyes) met inclusion criteria. Eighty-three patients (89.2%) were women (P < 0.00001), and 59 patients (63.4%) had bilateral disease. A normal age distribution was noted, with a mean age of 54.3 years (median, 53 years; standard deviation = 16.9). Meibomian gland dysfunction was noted in 51 patients (54.8%), contact lens wear in 31 patients (33.3%), peripheral vascularization in 29 patients (31.2%), pterygium in 15 patients (16.1%), keratoconjunctivitis sicca in 9 patients (9.7%), and exposure keratitis in 4 patients (4.3%). Forty-nine eyes (32.2%) of 37 patients (39.8%) required a total of 62 surgical procedures. Impaired vision led to 53 (85.5%) of these procedures and resulted in improved vision in 42 (79.2%) of these cases. Seven eyes (4.6%) underwent surgical intervention for subjective discomfort or contact lens intolerance, and all had improved symptoms at last follow-up. CONCLUSIONS: SNCD appears to be a disorder that occurs predominantly in middle-aged women and may be associated with chronic ocular surface inflammation and/or irritation. It is important to diagnose properly because of the good prognosis with medical and surgical therapy.

Treatment of acanthamoeba keratitis with intravenous pentamidine before therapeutic keratoplasty.

PURPOSE: The aim of this study was to evaluate the outcome of pretreatment of Acanthamoeba keratitis with intravenous pentamidine (IVP) before therapeutic keratoplasty (TKP). METHODS: A retrospective chart review was performed of the medical records of every patient treated with IVP before TKP for Acanthamoeba keratitis at a single, tertiary care eye center between January 1, 2002, and December 31, 2012. The main outcome measures were microbiological cure, graft survival, and visual outcome. RESULTS: Eight eyes of 7 patients met the inclusion criteria. Preoperatively, all 8 eyes had failed traditional antiamoebic therapy, including 5 eyes with recurrent infections after previous TKP. The patients were treated with IVP (190-400 mg/d) for a median of 14 days (range, 7-26 days). After 8 TKP, a microbiological cure was achieved, and a clear graft was maintained in 5 (62.5%) eyes during a mean follow-up interval of 31.2 months (range, 1.0-95.7 months). Repeat TKP in 3 eyes with recurrent Acanthamoeba keratitis resulted in 2 additional microbiological cures and 1 more clear graft. The final best-corrected visual acuity was ≥20/40 in 5 (62.5%) eyes and worse than 20/200 in 3 eyes. Overall, the final vision was improved in 6 (75.0%) eyes, remained the same in 1 (12.5%) eye, and was worse in 1 (12.5%) eye. CONCLUSIONS: The adjunctive use of IVP before TKP may assist with the achievement of microbiological cure, clear graft, and good visual outcome in a majority of eyes with Acanthamoeba keratitis.

Graft survival of diabetic versus nondiabetic donor tissue after initial keratoplasty.

PURPOSE: To compare corneal graft survival using tissue from diabetic and nondiabetic donors in patients undergoing initial Descemet stripping automated endothelial keratoplasty (DSAEK) or penetrating keratoplasty (PKP). METHODS: A retrospective chart review of pseudophakic eyes that underwent DSAEK or PKP was performed. The primary outcome measure was graft failure. Cox proportional hazard regression and Kaplan-Meier survival analyses were used to compare diabetic versus nondiabetic donor tissue for all keratoplasty cases. RESULTS: A total of 183 eyes (136 DSAEK, 47 PKP) were included in the statistical analysis. Among 24 procedures performed using diabetic donor tissue, there were 4 cases (16.7%) of graft failure (3 DSAEK, 1 PKP), and among 159 procedures performed using nondiabetic donor tissue, there were 18 cases (11.3%) of graft failure (12 DSAEK, 6 PKP). Cox proportional hazard ratio of graft failure for all cases comparing diabetic with nondiabetic donor tissue was 1.69, but this difference was not statistically significant (95% confidence interval, 0.56-5.06; P = 0.348). There were no significant differences in Kaplan-Meier curves comparing diabetic with nondiabetic donor tissue for all cases (P = 0.380). Statistical analysis of graft failure by donor diabetes status within each procedure type was not possible because of the small number of graft failure events involving diabetic tissue. CONCLUSIONS: We found similar rates of graft failure in all keratoplasty cases when comparing tissue from diabetic and nondiabetic donors, but further investigation is needed to determine whether diabetic donor tissue results in different graft failure rates after DSAEK compared with PKP.

Donor-to-host transmission of Candida albicans after corneal transplantation.

PURPOSE: To report donor-to-host transmission of Candida albicans after penetrating keratoplasty. DESIGN: Interventional case report. METHODS: A 15-year-old boy who underwent penetrating keratoplasty for keratoconus with donor tissue from a drowning victim developed keratitis and a lenticular abscess 26 days postoperatively. RESULTS: Candida albicans was cultured from the donor rim and the recipient cornea. Antifungal sensitivity profiles were identical for the two isolates. DNA profiles were identical for both isolates, confirming the donor as the source of the infection. CONCLUSION: This case demonstrates the value of routine culture of corneal donor rims and the advisability of close follow-up and possible antifungal prophylaxis when donor rims are positive for fungus.

Acanthamoeba keratitis after photorefractive keratectomy.

A 37-year-old women developed severe suppurative keratitis immediately after having photorefractive keratectomy in her left eye. The keratitis was unresponsive to intensive topical antibiotic agents and topical and systemic steroids. Although the differential diagnosis included nonmicrobial and fungal keratitis, the clinical course and confocal microscopy suggested, and subsequent histopathologic examination confirmed, a diagnosis of Acanthamoeba keratitis. The amebic contamination probably resulted from exposure of the deepithelialized cornea to contaminated freshwater in a northern Wisconsin marsh. This case emphasizes the importance of encouraging patients with epithelial defects and bandage soft contact lenses to avoid exposure to contaminated freshwater until reepithelialization is complete.

Graft survival versus glaucoma treatment after penetrating or Descemet stripping automated endothelial keratoplasty.

PURPOSE: The aim of this study was to assess and compare the association of glaucoma therapy with graft survival after performing penetrating keratoplasty (PKP) and Descemet stripping automated endothelial keratoplasty (DSAEK). METHODS: A retrospective chart review was performed of cases: primary PKP from January 1, 2003, to December 31, 2005, or primary DSAEK from January 1, 2006, to December 31, 2008. Eyes with a surgical indication of pseudophakic corneal edema were included in the statistical analysis. Eyes were stratified by glaucoma treatment into those with (1) no glaucoma treatment, (2) medical therapy only, or (3) surgical intervention. The main outcome measure was graft survival. RESULTS: Fifty-seven PKP-operated and 156 DSAEK-operated eyes met the inclusion criteria. After PKP and DSAEK, respectively, the 5-year Kaplan-Meier graft survival was 94.7% and 93.8% in eyes with no glaucoma treatment (P > 0.99), 93.8% and 96.3% in eyes with medical therapy only (P > 0.99), and 56.8% and 50% in eyes with surgical intervention (P > 0.99). After both procedures were performed, graft survival was significantly worse in eyes with surgical intervention compared with that in eyes with no glaucoma treatment (P < 0.0001) or in eyes with medical therapy alone (P < 0.0001). CONCLUSIONS: PKP and DSAEK have comparable graft survival in eyes without glaucoma management and in those with comparable glaucoma management.