Clinical Outcomes and Intraocular Pressure Control After Scleral-glued Intraocular Lens Insertion in Eyes With Pseudoexfoliation.

PURPOSE: To analyze clinical outcomes and intraocular pressure control following scleral-glued intraocular lens (IOL) fixation in eyes with pseudoexfoliation (PXF). METHODS: A retrospective chart review and outcome analysis was performed on a series of eyes undergoing glue-assisted, scleral-fixated (scleral-glued) IOL insertion in the setting of PXF and poor or absent capsular support. RESULTS: In total, 28 eyes were included in the study. The indications for scleral-glued IOL fixation included late endocapsular IOL dislocation (21/28, 75%), exchange for iris-fixated IOL due to complication (4/28, 14%), subluxed crystalline lens (2/28, 7%), and aphakia after complicated cataract surgery (1/28, 4%). In total, 15/28 (54%) eyes had diagnosed preexisting glaucoma at the time of scleral-glued surgery. The most common postoperative complication was ocular hypertension requiring escalation of medical management, which occurred in 8/28 (29%) eyes. At final follow-up, corrected distance visual acuity was equivalent to or improved from preoperative measurements in 25/28 (89%) eyes. CONCLUSIONS: The scleral-glued surgery is a good option for fixating an IOL in eyes with PXF and poor zonular integrity or absent capsular support. Special attention should be placed on intraocular pressure control following surgery, which can be less predictable in PXF eyes with or without preexisting glaucoma.

Descemet Stripping Endothelial Keratoplasty in Eyes With Previous Glaucoma Surgery.

PURPOSE: To evaluate visual outcomes and complications after Descemet stripping automated endothelial keratoplasty (DSAEK) in patients with previous glaucoma surgery. METHODS: A retrospective chart review was conducted of 129 procedures in 102 eyes of 96 patients who underwent DSAEK and previous glaucoma surgery at New York Eye and Ear Infirmary of Mt Sinai. The mean length of follow-up was 29.1 ± 25.5 months. Patients with postoperative follow-up duration of less than 3 months were excluded from analysis. Intraoperative and postoperative complications, postoperative course, and visual outcomes were analyzed. RESULTS: Graft dislocation occurred in 46 eyes (35.7%) and 38 eyes required repeat injection of air in the anterior chamber. Primary graft failure occurred in 3 eyes (2.3%), early graft failure in 20 eyes (15.5%), and secondary graft failure developed in 29 eyes (22.5%). There was a statistically significant increase in secondary graft failure in patients with previous aqueous shunt implantation compared with eyes with previous trabeculectomy (P = 0.03). Escalation of glaucoma therapy was needed medically in 25 eyes (24.5%), and 8 eyes (7.8%) required additional surgical intervention. CONCLUSIONS: There is a significant incidence of graft dislocation and graft failure after DSAEK in eyes with previous glaucoma surgery. In particular, aqueous shunt surgery compared with trabeculectomy may decrease long-term graft survival, and close follow-up is warranted.

Facilitating cortical aspiration after insertion of a capsular tension ring.

UNLABELLED: We describe a simple, effective technique to prevent the cortical entrapment that can occur after a capsular tension ring (CTR) is implanted during phacoemulsification. Before the epinucleus has been removed, the blunt tip of an ophthalmic viscosurgical device (OVD) cannula is burrowed centrally in the cortical/epinuclear plate and OVD is injected as the cannula is advanced. The cannula is turned superiorly and dissection continued to the lens equator. The cleavage plane is extended for approximately 2 clock hours in the direction of the intended CTR insertion. The CTR is then inserted below the cortical/epinuclear plate. FINANCIAL DISCLOSURE: None of the authors has a financial or proprietary interest in any material or method mentioned.

Outcomes of glued foldable intraocular lens implantation in eyes with preexisting complications and combined surgical procedures.

PURPOSE: To evaluate the visual outcomes and complications of glued foldable intraocular lens (IOL) implantation in patients with a wide range of ocular pathologies and/or having combined surgical procedures. SETTING: New York Eye and Ear Infirmary of Mount Sinai, New York, New York, USA. DESIGN: Retrospective case series. METHODS: A chart review was conducted of all glued foldable IOL procedures performed in eyes with absent or insufficient capsule support. Patients with a postoperative follow-up less than 3 months were excluded from analysis. Intraoperative and postoperative complications, the postoperative course, and visual and refractive outcomes were analyzed. RESULTS: Sixty-five eyes (64 patients) were evaluated over a mean follow-up of 9.1 months ± 6.2 (SD). Ocular comorbidities were present in 98.5% of eyes, and 95.4% had additional concurrent surgical procedures. There was a statistically significant improvement in corrected distance visual acuity (P = .046), with 89.2% of eyes achieving better or equal vision postoperatively. Intraoperative complications included ocular hemorrhage (10.8%), haptic deformation (10.8%), and haptic breakage (1.5%). Postoperative complications included elevated intraocular pressure (13.8%), optic capture (12.3%), persistent anterior chamber inflammation (6.2%), IOL tilt (4.6%), cystoid macular edema (3.1%), recurrent ocular hemorrhage (3.1%), and retinal detachment (1.5%). CONCLUSION: The glued foldable IOL technique resulted in favorable visual outcomes but with a moderate risk for IOL-related and other postoperative complications in eyes with complex ocular comorbidities having combined surgical procedures. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Detection of herpes simplex virus type 1 in failed descemet stripping automated endothelial keratoplasty grafts.

PURPOSE: To determine the prevalence of herpes simplex virus type 1 (HSV-1) DNA in failed Descemet membrane stripping automated endothelial keratoplasty (DSAEK) grafts. METHODS: A retrospective interventional case series of patients with DSAEK graft failure treated at the New York Eye and Ear Infirmary between January 2009 and July 2012 was performed. Repeat DSAEK, penetrating keratoplasty, or keratoprosthesis procedure was subsequently performed on eyes with failed grafts. All failed grafts were examined immunohistochemically and with qualitative real-time polymerase chain reaction for HSV-1 DNA. In HSV-1-positive cases, corneoscleral donor rims from the original DSAEK procedures were also examined immunohistochemically and with polymerase chain reaction. RESULTS: Fifty-one failed DSAEK grafts from 50 eyes of 49 patients were identified. Indications for DSAEK were pseudophakic bullous keratopathy (28/51, 55%), Fuchs corneal endothelial dystrophy (12/51, 23%), failed penetrating keratoplasty (7/51, 14%), corneal decompensation from glaucoma (2/51, 4%), herpetic endotheliitis (1/51, 2%), and failed DSAEK (1/51, 2%). Forty-three grafts (83%) were primary DSAEK graft failure. HSV-1 DNA was isolated from 2 of 51 failed DSAEK grafts (4.0%). The corresponding corneoscleral donor rims did not demonstrate the presence of HSV-1. CONCLUSIONS: Based on our results, HSV-1 infection plays a minor role in DSAEK graft failure. The data suggest that recipient reactivation, rather than donor transmission, plays a role in HSV infection.

Flap lift and repair of postoperative laser in situ keratomileusis complications at the slitlamp.

UNLABELLED: We describe a technique to treat flap complications after laser in situ keratomileusis while seated at the slitlamp biomicroscope. After topical anesthesia is applied to the cornea, a blunt corneal spatula is used to reflect the flap only to the extent necessary for epithelial debridement. A corneal rake or spatula is then used to remove retained epithelial cells from the stromal bed and underside of the flap. The epithelium is then debrided 1.0 mm to 2.0 mm outside the flap gutter. The increased depth perception with a slit beam greatly improves visualization and identification of the presence of residual epithelial cells or leftover debris after scraping. The slit beam also aids in proper repositioning of the flap after the procedure. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Endophthalmitis after descemet stripping endothelial keratoplasty with concave-oriented dislocation on slit-lamp optical coherence topography.

PURPOSE: To present the first reported case of Descemet membrane stripping endothelial keratoplasty (DSEK)-associated endophthalmitis with concave dislocation on slit-lamp optical coherence topography (SL-OCT). METHODS: An 86-year-old man underwent DSEK for corneal decompensation secondary to prior surgery. On all postoperative visits, a slit-lamp examination and SL-OCT were performed. RESULTS: On the first postoperative day, the lenticle was dislocated in a concave configuration as imaged with the SL-OCT. On the second postoperative day, the patient had eye pain, nausea, and increased intraocular pressure. On SL-OCT imaging, the concave configuration and fibrin stranding were imaged. With intraocular pressure lowering, the patient's pain subsided, and he was scheduled for a lenticle refloat the following day. The next day, endophthalmitis was diagnosed secondary to exuberant purulent inflammation. At surgery, the lenticle was removed, cultures were obtained, and pars plana vitrectomy and intravitreal injections were administered. Intraoperative cultures were positive for heavy growth of Streptococcus pneumoniae. CONCLUSIONS: Endophthalmitis is a potential complication for any intraocular procedure including DSEK. SL-OCT imaging postoperatively may reveal concave lenticle configuration and subtle anterior chamber fibrin stranding may be early sign of endophthalmitis.

In situ nuclear disassembly: efficient phacoemulsification without nuclear rotation using lateral sweep sculpting and in situ cracking techniques.

We describe an in situ nuclear disassembly technique using a simplified form of sculpting and cracking, enhanced by phacoemulsification technology with a Kelman-style tip. The technique does not require mobilization or rotation of the nucleus within the capsular bag, and hydrodissection is optional. The technique requires a Kelman-style curved tip and Kuglen hook and takes advantage of the versatility of the curved phacoemulsification needle for sculpting and cracking. Since in situ nuclear disassembly requires no rotation of the nucleus for extraction, it is useful in cases in which zonules are compromised or the surgeon suspects posterior lenticonus and the potential for loss of integrity of the posterior capsule.

Failed descemet-stripping automated endothelial keratoplasty grafts: a clinicopathologic analysis.

PURPOSE: To describe the clinicopathologic findings in failed Descemet-stripping automated endothelial keratoplasty (DSAEK) grafts. DESIGN: Retrospective, interventional case series. SETTING: New York Eye and Ear Infirmary. STUDY POPULATION: Twenty-one patients with 22 failed DSAEK grafts treated between March 1, 2006 and February 1, 2008. INTERVENTION: Repeat DSAEK or penetrating keratoplasty were performed in the eyes with failed grafts. All failed grafts were examined histopathologically. MAIN OUTCOME MEASURES: Histopathologic parameters studied in failed DSAEK grafts included endothelial cell count, interface characteristics, retrocorneal membrane formation, inflammation, and immunoreactivity for herpes simplex virus type 1 (HSV-1) antigen. RESULTS: DSAEK failure was strongly associated with postoperative lenticle dislocation. Graft failure was primary in 19 DSAEKs and secondary to rejection, eccentric trephination with epithelial ingrowth, or bacterial infection in the remaining 3. All failed grafts demonstrated endothelial hypocellularity and stromal edema. Additional findings included stromal inflammation (68%), interface fibrosis (50%), retrocorneal membrane (36%), unplanned retention of Descemet membrane (14%), immunoreactivity for HSV-1 (14%), paucicellular stroma (14%), and uneven trephination with epithelial ingrowth (5%). CONCLUSIONS: Most DSAEK failures are secondary to endothelial cell loss. Other contributing factors include interface fibrosis, retrocorneal membrane formation, retained host Descemet membrane, uneven trephination, epithelial ingrowth, graft rejection, and infection.

The use of postoperative slit-lamp optical coherence tomography to predict primary failure in descemet stripping automated endothelial keratoplasty.

PURPOSE: To determine if central donor lenticle thickness as measured by slit-lamp optical coherence tomography (SL OCT; Heidelberg Engineering, Heidelberg, Germany) is predictive of primary donor failure in patients undergoing Descemet stripping automated endothelial keratoplasty (DSAEK). DESIGN: Retrospective cross-sectional study. METHODS: Eighty-four patients who underwent DSAEK surgery by 2 surgeons (D.C.R. and J.A.S.) were enrolled. At each postoperative visit (postoperative day 1, week 1, month 1, and month 2), an SL OCT scan was obtained. Statistical differences in SL OCT measurements of successful and failed DSAEK procedures were measured using the Student t test. A successful DSAEK surgery was defined as having an anatomically attached, clear recipient corneal stroma and donor lenticle compatible with good vision 2 months after surgery. A failed DSAEK surgery was defined as an attached donor lenticle with SL evidence of corneal edema and thickening visible at 2 months or more. RESULTS: Ninety-three eyes of 84 consecutive patients who underwent DSAEK surgery also underwent postoperative SL OCT. After 2 months of follow-up, 82 (88%) procedures were successful and 11 (12%) procedures were failures. The average donor lenticle thickness in successful DSAEK eyes was 314 +/- 128 microm on postoperative day 1 as compared with failed DSAEK eyes, which averaged 532 +/- 259 microm (P = .0013). This was independent regardless of whether the lenticle was attached on the first postoperative visit. Seventy-nine (98%) successful DSAEK eyes had a lenticle thickness of < or = 350 microm at the 1-week visit. All of the failed DSAEK eyes (11 eyes) had a lenticle thickness > or = 350 microm at the 1-week postoperative visit. Statistically significant differences in SL OCT thickness measurements were seen between successful and failed DSAEK cases at all examinations after postoperative week 1. CONCLUSIONS: Corneal thickness measurements made with SL OCT are an important predictor of DSAEK failure in both attached and detached lenticles within the first week of surgery. DSAEK lenticle thickness of 350 microm or less at 1 week had a predictability of success of more than 98%.

The prevalence and pathogenicity of Propionibacterium acnes keratitis.

PURPOSE: To study the prevalence, pathogenicity, and virulence of Propionibacterium acnes keratitis. METHODS: All cases of infectious keratitis submitted to the microbiologic laboratory of the New York Eye and Ear Infirmary between January 1, 2003, and April 6, 2006, were reviewed. Those cases in which P. acnes was recovered from culture were collected, and the medical records studied in depth. RESULTS: Of 1555 cultures submitted to the microbiology laboratory, 1329 (85.5%) were positive for growth. One hundred twenty four (9.3%) of the 1329 cases yielded P. acnes in at least 1 culture medium. Seventy eight (62.9%) of 124 cases had not been pretreated with antibiotics before culture, and 66.7% of the nonpretreated ulcers were monomicrobial (P. acnes only). Fifty one (65.4%) of 78 cases of the nonpretreated corneal ulcers presented with a cellular reaction in anterior chamber, 12 (15.4%) with a hypopyon (6 were monomicrobial), 21 (26.9%) had stromal thinning (12 of which were monomicrobial), and 2 (2.6%) progressed to perforation (both polymicrobial). Corneal ulcers associated with P. acnes tended to be small (66.7%) and were widely distributed: central (n = 17, 21.8%), paracentral (n = 44, 56.4%), and peripheral (n = 17, 21.8%). The most common risk factors were contact lens wear and previous history of ocular surgery. Three of the 78 nonpretreated patients were unresponsive to medical treatment and required surgery for keratitis. CONCLUSION: This study provides evidence that P. acnes is a frequent cause of bacterial keratitis and may cause significant morbidity.

Isolation, purification and cultivation of conjunctival melanocytes.

The purpose of the present study was to develop methods for isolation, purification and cultivation of human conjunctival melanocytes. Conjunctiva excised from donor eyes or corneal rims was subjected with various enzyme digestion methods or by the enzyme-microdissection method. Cells were cultured with F12 medium supplemented by fetal bovine serum, basic fibroblast growth factor, isobutylmethylxanthine and cholera toxin. Contaminant cells were eliminated by a selective cytotoxic agent, geneticin. Both trypsin digestion and dispase-microdissection methods provided pure conjunctival melanocyte cultures with high cell yields, good viability and rapid growth rate. Melanocytes isolated with dispase-microdissection method showed better viability and growth capacity. Cells grew well, could be passaged for 5-10 generations and divided 20 times in vitro. They maintained a constant melanin content per cell and produced measurable amounts of melanin in vitro. Melanogenesis correlated with the degree of pigmentation of the eyes (iris color). This method provides a valuable source of large numbers of human conjunctival melanocytes, which can be used to study their biological behavior, to compare with the epidermal and uveal melanocytes; and to compare them to their malignant counterparts in the exploration of the pathogenesis of conjunctival melanoma.

Fungal keratitis at the new york eye and ear infirmary.

INTRODUCTION: This study was designed to review the clinical experience at our institution with fungal keratitis during a 16-year period. MATERIALS AND METHODS: A review of the clinical and microbiology records of the New York Eye and Infirmary identified 61cases of fungal keratitis in 57 patients between January 1, 1987 and June 1, 2003. The medical records of all patients were retrospectively reviewed to better delineate patient demographics, risk factors, etiologic organisms, treatment, and outcomes. RESULTS: A total of 5083 positive corneal cultures were recorded'from January 1, 1987 to June 1, 2003. Sixty-one eyes in 57 patients (37 women) were positive for fungus (1.2%). Three'patients had bilateral simultaneous infections. Candida albicans accounted for 29 of 61 cases (48%). Human immunodeficiency virus (HIV) seropositivity (15 eyes), chronic ocular surface disease (14 eyes), and trauma (7 eyes) were the most commonly associated risk factors. CONCLUSIONS: Our experience with fungal keratitis in the northeastern United States appears to be different than those reported from other areas of the United States. Serologic positivity for HIV and chronic ocular surface disease were the most common associated risk factors followed by trauma, herpes simplex keratitis, and contact lens use. Candida species predominated, whereas filamentous fungi were uncommon.

Liquid bandage (2-octyl cyanoacrylate) as a temporary wound barrier in clear corneal cataract surgery.

PURPOSE: To determine the feasibility and side effect profile of 2-octyl cyanoacrylate with parabens (Liquid Bandage) as an adjunct wound sealant and barrier against the inflow of ocular surface fluid after clear corneal cataract surgery. DESIGN: Prospective interventional case series. PARTICIPANTS: Fifty-one eyes of 51 patients undergoing clear corneal cataract surgery. METHODS: Fifty-one eyes of 51 patients who underwent cataract surgery by one surgeon (RSK) were enrolled. A 2.75-mm clear corneal, triplanar, temporal incision was used in each case, followed by routine phacoemulsification. At the conclusion of each case, the wound was dried with a cellulose sponge. A modified microsponge with 1 to 2 drops of 2-octyl cyanoacrylate with parabens was then applied in a smooth layer to the wound. All wounds were rechecked for leakage with a cellulose sponge applied at the wound lip. The following criteria were evaluated on the first 2 postoperative visits: (1) visual acuity; (2) patient complaints; (3) wound integrity; (4) presence of tissue adhesive; and (5) any adverse events, including abnormal increase in local tissue reaction to the adhesive. MAIN OUTCOME MEASURES: Side effect profile and clinical course of 2-octyl cyanoacrylate with parabens applied to clear corneal wounds. RESULTS: All 51 eyes demonstrated intraoperative watertight wound closure after the application of 2-octyl cyanoacrylate with parabens. Forty-five eyes (88%) had tissue adhesive still completely covering the wound on postoperative day 1. Two eyes (4%) had tissue adhesive over portions of their wound, and 4 eyes (8%) had no adhesive noted on their wound. All wounds were watertight on all postoperative visits. Thirty-one of 51 patients (61%) complained of mild transient foreign body sensation on postoperative day 1. Twenty-six patients (51%) had trace diffuse bulbar conjunctival hyperemia. Five patients had trace focal conjunctival hyperemia adjacent to the wound. Nine patients (18%) had remnants of the adhesive remaining on the second postoperative visit. CONCLUSIONS: Our study demonstrates the ease of use and applicability and low side effect profile of 2-octyl cyanoacrylate with parabens as a temporary wound barrier in clear corneal cataract surgery.

Assessment of central corneal thickness using optical coherence tomography.

PURPOSE: To demonstrate the capability of model OCT3 optical coherence tomographer to evaluate central corneal thickness (CCT) in normal human corneas in vivo and compare the results with the those of standard ultrasound (US) pachymetry and Orbscan. SETTING: New York Eye & Ear Infirmary Resident Clinic, New York, New York, USA. METHODS: The CCT in 22 eyes of 11 subjects was determined with the OCT3 (Carl Zeiss Meditec), Orbscan (Bausch & Lomb, Inc.), and US pachymetry (DGH Technology, Inc.). Three central corneal scans of each eye were obtained using the OCT3. First, OCT3 data were processed using the standard OCT software program (OCT3(std)). Second, OCT3 raw data were exported and measurements were repeated using Scion Image for Windows program (OCT3(sci)). The OCT3 and Orbscan results were compared with the mean of 5 US pachymetry measurements in each eye. RESULTS: The OCT3(std), OCT3(sci), and Orbscan CCT measurements showed high correlations with US pachymetry (r=0.981, r=0.984, and r=0.942, respectively; P<.0001). Bland-Altman analysis showed a high level of agreement between US pachymetry and OCT3 techniques but not Orbscan. High repeatability for OCT3(std) (r(2)=0.05) and OCT3(sci) (r(2)=0.01) was also seen. CONCLUSION: Results show the OCT3 is an accurate, noninvasive, and reproducible technique for evaluation of CCT.

Complications arising from iris-fixated posterior chamber intraocular lenses.

Iris fixation of posterior chamber intraocular lenses (IOLs) is a technique that has been recommended for patients in whom a posterior chamber IOL is indicated but there is insufficient capsular support. We present 4 cases of iris-fixated posterior chamber IOLs with complications related to the procedure. Three patients developed postoperative slippage of the IOL, and 1 patient presented with iris erosion of the haptic leading to recurrent hemorrhage. Three cases were repaired by resuturing the same IOL using iris fixation, and in the last case IOL exchange with transscleral fixation of a posterior chamber IOL was performed. Final follow-up revealed stable IOLs in all cases.