Posttraumatic intraocular pressure elevation and associated factors in patients with zone I open globe injuries.

BACKGROUND: The object of this study was to determine factors that might be associated with intraocular pressure (IOP) elevation after anterior segment open globe injuries (zone I). METHODS: Data were obtained from the records of 68 patients who experienced zone I open globe injury between January 2008 and October 2010. Group I was composed of patients with chronically elevated IOP of at least 21 mmHg within a 1-year follow-up period. The rate of posttraumatic IOP elevation and associated structural and functional risk factors were evaluated. RESULTS: Of the 68 patients, 17 (25%) developed posttraumatic IOP elevation (Group 1). The mean age in group I was significantly older compared to group II (36.8±24.4 and 15.7±15.3 years, respectively [p=0.003]). Iris damage, postoperative inflammation, and use of long-term corticosteroids were significantly greater in group I (p<0.001, p<0.001, p=0.005 respectively). In group I, 13 of 17 patients (76.5%) had a wound size larger than 6 mm compared to only one patient (1/51, 2%) in group II, and the result was statistically significant (p<0.001). The size of wound larger than 6 mm also retained its statistical significance in multivariate analysis (p<0.001, odds ratio: 162.5). CONCLUSION: This study shows a significant relationship between larger wound size (>6 mm) and elevation of IOP after trauma in zone I open globe injuries.

Keratoconus in a case of lipoid proteinosis.

PURPOSE: To report a patient of lipoid proteinosis (LP) with bilateral keratoconus. METHODS: A 16-year-old boy presented to our institution with a complaint of gradual decrease in vision over the past 4 years in both eyes and a contact lens intolerance. He had a hoarse voice and multiple areas of hyperpigmented lesions over the head and neck region. Slit lamp biomicroscopy of the both eyes showed multiple round solid pearly lesions along the upper and lower lid margins and a mild central corneal ectasia in both eyes. Central corneal thickness and the keratometric values were measured by using Scheimpflug imaging (Pentacam), and the results were compatible with keratoconus. The histopathologic examination of the lesions taken from bilateral eyelid margins showed hyalinosis, papillomatosis, and depositions of eosinophilic material around the blood vessels, which were compatible with LP. CONCLUSIONS: With this report, we describe a case of LP with keratoconus. As seen in our case, LP and its characteristic eyelid margin lesions in keratoconus patients can be associated with a contact lens intolerance.

Changes in higher order wavefront aberrations after contact lens corneal refractive therapy and LASIK surgery.

PURPOSE: To compare ocular higher order aberrations induced by corneal refractive therapy (CRT, Paragon Vision) to those produced by LASIK for patients with comparable levels of myopia. METHODS: A retrospective chart review of 11 patients who used CRT lenses and 12 patients who underwent LASIK for correction of low to moderate myopia was performed. Uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BSCVA), manifest refraction, and optical higher order aberrations were recorded before and 1 month after treatment for each patient. RESULTS: The CRT group consisted of 11 patients (4 men, 7 women) with a mean age of 29.1+/-5.2 years (range: 23 to 40 years), and the LASIK group consisted of 12 patients (3 men, 9 women) with a mean age of 39.2+/-12.0 years (range: 23 to 60 years). Manifest refraction decreased statistically significantly from -2.81+/-1.05 diopters (D) at baseline to -0.77+/-0.64 D following CRT treatment at 1 month (P<.0001) and from -3.11+/-1.21 D at baseline to -0.43+/-0.27 D at 1 month after LASIK (P<.0001). Both CRT and LASIK exhibited no significant changes in total higher order aberrations for 4-mm pupils but induced statistically significant increases in total higher order aberrations for 6-mm pupils. Corneal refractive therapy and LASIK both exhibited statistically similar factors of change for total higher order aberrations and coma-like higher order aberrations for 6-mm pupils. Corneal refractive therapy demonstrated a statistically significant greater factor of increase in spherical-like higher order aberrations for 6-mm pupils (P=.01). CONCLUSIONS: Contact lens corneal refractive therapy and LASIK can effectively correct myopia, but both increase higher order aberrations for 6-mm pupils to a similar degree. However, spherical-like aberrations were statistically significantly greater after CRT than after LASIK.

Third or greater penetrating keratoplasties: indications, survival, and visual outcomes.

PURPOSE: The purposes of this study were to report the indications, graft survival, risk factors for graft failure, and visual outcomes for third or greater penetrating keratoplasties (PKP). METHODS: Six years of Wills Eye Institute Cornea Service charts (2000-2005) were retrospectively reviewed to identify all patients who had undergone three or more PKPs. Graft survival rates by initial diagnosis and risk factors for graft failure were analyzed. RESULTS: Forty-five patients who had three or more PKPs were identified. The total number of grafts identified in these 45 patients was 152, including 45 third PKPs, 11 fourth, three fifth, two sixth, and one seventh. The most common indication for the initial PKP was pseudophakic bullous keratopathy in 18 of 45 patients (41%) followed by Fuchs dystrophy (seven of 45 patients [16%]) and stromal dystrophies (five of 45 patients [11%]). Approximately half of third grafts (24 of 45 [53%]) and one fourth of fourth grafts (three of 11 [27%]) survived at the last follow-up visit with a median follow up of 4.3 years for the third grafts and 8.4 years for the fourth grafts. One-, 2-, and 5-year graft survival rates were 89%, 78%, and 53% for the third grafts and 73%, 73%, and 64% for the fourth grafts, respectively. The median survival time for the third graft was 12.8 years in Fuchs dystrophy, 5.2 years in herpetic keratitis, 4.0 years in keratoconus, 3.0 years in pseudophakic bullous keratopathy, 2.3 years in iridocorneal endothelial syndrome, and 2.0 years in stromal dystrophies. There is no statistically significant difference between groups (P = 0.46). Risk factor analysis on the third grafts showed that previous glaucoma procedures and corneal neovascularization are statistically significant risk factors for graft failure (P = 0.04 and 0.02, respectively). CONCLUSION: Over 50% of third and fourth grafts were clear at 5 years postoperatively. Outcomes of third grafts were better in patients with Fuchs dystrophy, keratoconus, and herpetic keratitis. Absence of previous glaucoma surgery and/or corneal neovascularization is associated with better outcomes of multiple PKPs.

Demographics of patients older than 50 years with keratoconus.

PURPOSE: This study was designed to determine the demographics of patients aged 50 years or more with a diagnosis of keratoconus, who were seen on the Cornea Service at Wills Eye Hospital. METHODS: A retrospective chart review of all patients with the diagnosis of keratoconus was undertaken to identify demographics characteristics between January 1, 2005 and December 31, 2005. RESULTS: A total of 697 patients were identified. Two hundred seventy-nine (40.0%) patients were age 50 years or more. The age ranged from 50 to 93 years (average 60.2 +/- 8.2 years). Keratoconus was diagnosed as a bilateral disease in 266 (95.3%) and as a unilateral disease in 13 patients (4.7%). In 186 patients (66.6% of the total), the average age at the time of diagnosis was 31.7 +/- 10.9 years (range from 13 to 70 years). Of the 279 patients, 167 had surgery (59.8%). In the group of 112 patients that did not have surgery, 25 (9.0%) were treated with glasses in both eyes, 85 (30.5%) with contact lenses in both eyes, and 2 (0.7%) with glasses in one eye and contact lenses in the other eye. The average time of follow-up was 13.6 +/- 10.5 years (range from 0.1 to 38.7 years). CONCLUSIONS: In a corneal referral practice, the number of patients older than 50 years with keratoconus is higher than previously reported in the literature. We believe that this is because our practice has a strong interest in both contact lenses and corneal surgery with the ability to follow up patients on a long-term basis.

Comparative study of graft rejection in keratoconus patients with and without self-reported atopy.

PURPOSE: To compare the incidence and characteristics of graft rejection in keratoconus patients with and without self-reported atopy. METHODS: From November 2007 to February 2008, 75 consecutive keratoconus patients who had undergone penetrating keratoplasty completed a questionnaire regarding personal history of atopy. The questionnaires were reviewed without knowledge of history of graft rejection. The patients were divided into three groups: nonatopic (group 1), mild atopic (group 2), and severe atopic (group 3). Charts were retrospectively reviewed with regard to the incidence and characteristics of graft rejection episodes for each patient. RESULTS: There were 13 patients in group 1, 36 patients in group 2, and 26 patients in group 3. The incidence of graft rejection (rejection episodes per 100 person-years) in groups 1, 2, and 3 was 7.3, 15.8, and 13.4, respectively. Although the mild and severe atopic groups had roughly twice the rate of rejection of the nonatopic group, there was no statistically significant difference among the groups (P = 0.25). The mean age of 37.1 +/- 8.9 years at the time of surgery was significantly lower (P = 0.004) and the rate of bilateral penetrating keratoplasty was significantly higher (40/55 eyes 73%) (P = 0.01) in group 2 than in the two other groups. The majority of first graft rejection episodes were mild or moderate in atopic patients (69% in group 2 and 94% in group 3) and severe (50%) in nonatopic patients; however, no significant difference was found among the groups (P = 0.13). CONCLUSIONS: Atopic conditions may increase the incidence of graft rejection in keratoconus patients, and the characteristics of graft rejection in atopic patients may differ from those in nonatopics because of the immune alteration, but differences in this study were not statistically significant.

Steroid-induced intraocular pressure elevation or glaucoma after penetrating keratoplasty in patients with keratoconus or Fuchs dystrophy.

PURPOSE: The aim of the present study was to evaluate the frequency of steroid-induced intraocular pressure (IOP) elevation and/or glaucoma in patients with keratoconus (KCN) compared with patients with Fuchs endothelial dystrophy after penetrating keratoplasty (PK). METHODS: A retrospective review of the medical records of patients with KCN or Fuchs dystrophy, who underwent PK and were examined on the Cornea Service, Wills Eye Institute, was performed. IOP measurements were recorded preoperatively; postoperative first month and maximal IOP measurements between 1 and 3 months, 4 and 6 months, 7 and 12 months, 1 and 2 years, 2 and 3 years, and 3 and 4 years were noted. Steroid-induced IOP elevation and/or glaucoma were grouped into 5 different categories; an increase in IOP of at least 5 or 10 mm Hg over the preoperative baseline and also IOP > or =22, 30, and 40 mm Hg. Addition of glaucoma medications and/or characteristic glaucomatous optic disc and visual field changes were also assessed. RESULTS: A total of 100 patients with KCN and 58 patients with Fuchs dystrophy were included in this study. The overall frequency of steroid-induced IOP elevation after PK was 73% in the KCN group and 60.3% in the Fuchs dystrophy group. The frequency of IOP elevation of at least 5 or 10 mm Hg over the preoperative baseline were 72% and 24% in KCN group and 56.9% and 20.7% in the Fuchs dystrophy group, respectively. The frequency of IOP elevation > or =22 or > or =30 mm Hg was 22% and 6% in the KCN group and 29.3% and 1.7% in the Fuchs dystrophy group, respectively. There was one patient in the KCN group who had IOP >40 mm Hg. There was no difference between the groups in terms of frequency of IOP elevation (P > 0.05 for all). Glaucomatous visual field defect was detected in 4 patients in the KCN group and only one patient in the Fuchs dystrophy group. Despite the maximum medical therapy, 2 patients in the KCN group underwent glaucoma surgery and none in the Fuchs dystrophy group. CONCLUSION: Steroid-induced IOP elevation or glaucoma after PK is not unusual in eyes with KCN or Fuchs dystrophy. Careful and ongoing observation of IOP throughout the prolonged follow-up period is recommended for these individuals with prompt attention to IOP treatment as indicated.

Fluorophotometry to evaluate the corneal epithelium in eyes undergoing contact lens corneal reshaping to correct myopia.

PURPOSE: To determine whether use of Corneal Refractive Therapy (CRT, Paragon Vision Sciences) lenses have an adverse effect on the health of corneal epithelium by monitoring epithelial permeability by fluorophotometry. METHODS: Eight patients with healthy eyes and whose refractive error was between -0.50 and -4.00 diopters (D) sphere and up to -1.75 D of astigmatism were enrolled. On the day of the fitting, two baseline fluorometric scans of the right eye were taken using the Ocumetrics Fluorotron Master. After 15 minutes, another two scans were taken of the right eye. The same fluorophotometry technique was repeated on day 1, 1 week, 1 month, and 3 months after the patient began overnight wear of the lenses. Patients' baseline corneal fluorescein levels and peak corneal fluorescence values after rinsing were compared to initial pre-fitting values to determine changes in corneal epithelial permeability. RESULTS: After patients used orthokeratology, uncorrected visual acuity was 20/20 or better in 9/16 eyes and 100% had achieved 20/40 or better by day 7. No adverse events were seen in patients utilizing orthokeratology, and eye examinations for these patients continued to be within normal limits. After nightly use of orthokeratology for 1 month, baseline fluorescence of the cornea (15.64 +/- 2.29 ng/mL vs 17.31 +/-5.43 ng/mL, P = .80) remained stable, and the post-15 minute scan peak corneal fluorescence values did not show significant changes from the pre-fitting (51.46 +/- 17.28 ng/mL) after use of orthokeratology (63.80 +/- 41.25 ng/mL) (P = .78). CONCLUSIONS: Reshaping of the cornea through the use of orthokeratology does not have adverse effects on corneal epithelium as evaluated by changes in corneal epithelial permeability.

Prospective comparison of two suturing techniques of amniotic membrane transplantation for symptomatic bullous keratopathy.

PURPOSE: To determine the outcomes of a modified amniotic membrane transplantation (AMT) suturing technique for pain and discomfort relief in patients with symptomatic bullous keratopathy (BK). DESIGN: Randomized, double-blind controlled clinical trial. METHODS: setting: Ankara Research and Training Hospital 1st and 2nd Eye Clinics, Ankara, Turkey. study population: This prospective study included 39 eyes (39 patients) with BK presenting with intractable pain or discomfort and poor visual potential. intervention: Patients were randomly assigned into two groups: in group 1 (21 patients), patients underwent a modified AMT suturing technique; a groove was prepared by vacuum trephine on the recipient cornea and the edges of the punch-shaped amniotic membrane (AM) were sutured to this groove with the basement membrane side up. In group 2 (18 patients), patients underwent the standard AMT suturing to the cornea. main outcome measure: During a mean follow-up of 27.3 +/- 8.5 months (standard deviation) (range, 12 to 36 months), epithelial healing, persistence of AM, pain relief, and visual changes were analyzed and were compared between groups. RESULTS: The mean age (P = .15), the mean follow-up (P = .73), and the mean preoperative visual acuity (P = .53) were similar in both groups. With the modified suturing technique, the postoperative visual acuity was better (P = .03), epithelialization time was shorter (P < .001), and the AM remained longer (P < .001). Successful epithelialization was achieved in 20 eyes (95.3%) in group 1, and in 16 eyes (88.9%) in group 2 (P = .586). The pain scores of patients in group 1 remained stable (P = .223) over time, however increased from the first week to the third month postoperatively in group 2 (P = .046). CONCLUSIONS: The modified AMT suturing technique has a similar epithelialization rate to standard AMT suturing to cornea. Though technically more demanding, shorter epithelialization time, longer persistence of AM, and stable pain scores in the postoperative period makes this a promising method for the treatment of symptomatic BK.

Basal cell carcinoma in lacrimal sac.

A 53-year-old woman was admitted to the hospital one year after the onset of her complaints. She suffered from epiphora and swelling in the lacrimal sac region. Biopsy revealed islets of classical basal cell carcinoma with peripheral formation of palisades within a hyperemic stroma. During surgery, the lacrimal drainage system and neighboring bony structures were completely excised. No local recurrences were detected on orbital tomography performed 6 and 15 months postoperatively. As far as the authors know, this is the first case of basal cell carcinoma in the lacrimal sac reported in the literature.